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THE 



READY REFERENCE HANDBOOK 



DISEASES OF THE SKIN. 



GEORGE THOMAS JACKSON, M. D. (Col.), 

CHIEF OF CLINIC AND INSTRUCTOR IN DERMATOLOGY, COLLEGE OF PHYSICIANS 
AND SURGEONS, NEW YORK; CONSULTING DERMATOLOGIST TO THE PRESBY 
TERIAN HOSPITAL, NEW YORK, AND TO THE NEW YORK INFIRM- 
ARY FOR WOMEN AND CHILDREN ; MEMBEE OF THE AMERI- 
CAN DERMATOLOGICAL ASSOCIATION AND OF THE 
NEW YORK DERMATOLOGICAL SOCIETY. 



WITH 80 ILLUSTRATIONS AND 3 PLATES. 



FOURTH EDITION, THOROUGHLY REVISED. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 
1901. 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

AUG. 10 1901 

COPVRIGHT ENTRY 
JtUJ, /(}. l<fOf 

CLASS ^XXc. N«. 
COPY B. 






Entered according to Act of Congress, in the year 1901, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



PREFACE TO FOURTH EDITION. 



It is a source of satisfaction that a new edition has so 
soon been called for. The author has spared no effort to 
keep this work abreast of its subject at the date of each 
revision, and the public has done its full share in afford- 
ing frequent opportunities of this kind. It is hoped that 
the book shows the benefit of this benign cycle in its 
increasing adaptation to the needs of both students and 
practitioners. 

New sections have been added on Acne keratosa, Acne 
urticata, Carate, Craw-craw, Endothelioma, Erythro- 
dermie pityriasique en plaques disseminees, Fordyce's 
disease of the lips, Granuloma necrotica, Impetigo of 
Bockhardt, Lichen annularis, Lichen pilaris, Pityriasis 
lichenoides chronica, and Verruga Peruana. 

It will be noticed that in spite of the new subject-mat- 
ter the book has not increased in size. This is due to the 
careful pruning of the old text, and the omission of pro- 
nunciations, a step taken because at present there is no 
generally recognized standard in regard to many of the 
names used ; and also because a dictionary is really the 
proper place in which to look for them. 

Five new illustrations have been added, for which the 
author renders his thanks to his friends Drs. George H. 
Fox and S. Dana Hubbard. 

G. T. J. 

14 East Thirty-first Street, 

New York, Julv, 1901. 



PREFACE TO FIRST EDITION. 



The following pages are intended to present the art of 
dermatology as it now exists. No attempt has been made 
to discuss debatable questions. Hence pathology and eti- 
ology do not receive as full consideration as symptoma- 
tology, diagnosis, and treatment. 

The alphabetical arrangement of the different diseases 
has been adopted for convenience of ready reference. It 
is hoped that the large number of titles from foreign lan- 
guages will prove as acceptable as it is novel. I would 
impress upon the reader the fact that in the prescriptions 
given no attempt has been made to translate grains, 
drachms, and ounces into their precise equivalents in 
grammes, but simply to preserve the relative percentages 
of the ingredients in the old formulae and express them 
in decimals. The decimals may be regarded as either 
grammes or parts. 

It gives me pleasure to acknowledge in this place 
and always my great obligations to my friends, Drs. 
George Henry Fox, Edward Bennett Bronson, and 
Robert William Taylor. To the first two I owe much 
of whatever knowledge of dermatology I may possess, 
and from all of them I have received many of those 
kindly courtesies that make a professional life worth 
living. 

I would also acknowledge my indebtedness to Dr. A. 



6 PREFACE TO FIRST EDITION. 

Rupp fur special contributions upon eczema and furuncles 
of the ear, and to all those worker- in dermatology from 
whose writings I have drawn freely so as to make this 
little book a presentation of modern dermatology. The 
admirable text-book of Dr. H. R. Crocker, of London, 
has been specially consulted by me, and has guided me 
through many difficulties. 

Messrs. William Wood & Co. and D. Appleton & Co. 
have most courteously permitted me to make use of some 
papers of mine published in The Medical Record, T < 
New York Medical Journal, and The Journal of Cutaneous 
and Genito- Urinary Diseases during the past years. 

G. T. J. 

14 East Thirty-first Strket, 

New York, August, 1892. 



DISEASES OF THE SKIN. 



PAET I. 
GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

Before we enter upon the consideration of the separate 
diseases of the skin it will be well for us to refresh our 
memory as to its anatomy. It is not my desire to give a 
complete and exhaustive chapter on this subject, but to 
draw attention to those properties of the cutaneous enve- 
lope that are of practical importance to us. 

The skin is composed of three distinct layers, namely : 
1, the epidermis ; 2, the derma, also named the cutis vera, 
or corium ; and, 3, the subcutaneous connective tissue. 
The appendages of the skin are the hair, the nails, the 
sebaceous and the sweat glands. This complicated struct- 
ure is supplied with blood vessels, lymphatics, and nerves. 

Epidermis. The epidermis is composed of four layers, 
called strata, namely : 1, the stratum corneum ; 2, the 
stratum lucidum ; 3, the stratum granulosum ; and, 4, the 
stratum mucosum. Of these strata, the two that most 
concern us are the first and the last — that is, the stratum 
corneum and the stratum mucosum. The other layers of 
the skin may, for our present purpose, be regarded as 
simply transition-layers through which an epithelial cell 
passes on its developmental way to become a fully formed 
and rightly compacted corneous cell. Each of the four 
strata of the epidermis is divided again into layers, but 
these are of no practical importance. The thickness of 
the epidermis varies greatly, being thickest and most com- 

2 17 



lb 



GENERAL CONSIDERATIONS. 
Fig. 1. 




Vertical section through the skin. Diagrammatic. (After Heitzmann.) 

pact where it is subjected to the most pressure of inter- 
mittent character, as on the palms and soles. 

The stratum comeum consists of a series of superimposed 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 19 

layers of flattened, elongated cells that increase in flatness 
from below upward. The upper layers are called scales. 
The cells of each layer are united to each other so much 
closer than the layer itself is united to those above and 
below it that when an effusion takes place into the stratum 
corneum a layer of cells in the affected area is raised and 
the fluid is found between two layers. The lamellated 
scaling met with in certain scaly diseases, such as der- 
matitis exfoliativa, in which great plates of scales are 
readily removable, is likewise due to this close relation 
between the cells of each layer. This stratum is largely 
a protective one, its compactness affording a fair degree 
of resistance to injury of the underlying, more succulent 
layers of the epidermis. 

The stratum mucosum is the deepest layer of the epider- 
mis, and is seated upon the papillary layer of the corium. 
It is composed of several layers of cells, but may be consid- 
ered as consisting of two chief layers, namely, the columnar 
epithelium and the prickle cells. The columnar epithelial 
cells are arranged perpendicularly to the papillae of the 
corium, while the prickle cells, which are polygonal in 
shape with spherical nuclei and with little filaments run- 
ning out from their sides toward the neighboring cells, are 
arranged in strata over them. As the stratum granulosum, 
which lies above the stratum mucosum, is approached the 
prickle cells become flatter, and finally lie with their long 
axis parallel to the general surface. The "granules" 
contain eleidin (Ranvier) and keratohyalin (Waldeyer), 
the former being a solid and the latter a fluid substance. 
The stratum mucosum, also called the rete Malpighii, is 
the most important stratum of the epidermis, and the seat 
of that most common of all skin diseases, eczema. From 
its lower part it sends down projections between the 
papilla? of the corium, which are called interpapillary 
projections. Most of the pigment of the skin is situated 
in the lower part of the stratum mucosum. As the upper 
part is approached less and less pigment is found. The 
pigment itself is in the form of granules and of diffused 
coloring-matter. According to Unna, the pigment is 
found even in the upper part of this layer, while in path- 



20 GENERAL CONSIDERATIONS. 

ological conditions it may be located in the corium. In 
the so-called colored races pigment is always found in the 
corium, and even the horny layer is stained. 

From this arrangement of the cells of the epidermis it 
will be seen that nutrient fluids can readily work upward 
from below by means of the little channels formed by the 
interlacing of the filaments running between the cells. 

The epidermis has no blood vessels. It receives its nu- 
trition entirely from the corium. Though there are no 
true lymphatics in the epidermis, there are abundant 
lymph spaces between the cells that take their place. 
Nerves of the non-medullated variety have been traced 
between the cells of the epidermis, and have been de- 
scribed by some histologists as entering into the cells to 
end at the nucleus, though not to enter it. The final dis- 
tribution of the nerves in the epidermis is not yet fully 
determined. 

Corium. The corium is composed of white fibrous and 
yellow connective tissue, disposed in horizontal bundles 
above and in oblique bundles below. It is a very dense 
and tough tissue, and is pierced in all directions to allow 
of the passage of blood vessels, lymphatics, sweat ducts, 
and nerves, and affords lodgement for the hair follicles 
and sebaceous glands. It contains a considerable amount 
of elastic fibers. The upper part has been named the 
pars papillaris, and the lower part thenars reticularis corii. 
From its upper part it sends off a vast number of projec- 
tions called papfflce. These vary in length, being longest 
and most marked on the ends of the fingers and toes. 
The epidermis follows these projections and dips down 
between them. They are readily seen as parallel mark- 
ings on the ends of the fingers. Over most of the body 
surface the papillae are but slightly raised, and merely 
give a wavy appearance to the upper edge of the corium 
when viewed under the microscope. A fine basement- 
membrane separates the corium from the epidermis. This 
is regarded by some as a cement-substance. As the lower 
part of the corium is readied the bundles of fibers are less 
closely crowded together, and becoming successively looser 
gradually pass over into the 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 21 

Subcutaneous connective tissue. This is a loose connec- 
tive tissue with large and small spaces in it, which are 
filled with adipose tissue. This consists of fat-cells 
collected into lobulated masses that in some cases have 
about them a connective-tissue sheath. Each lobule is 
supplied with an afferent artery, a capillary plexus about 
it, and efferent veins. This part of the skin is called the 
panniculus adiposus, and is found everywhere except in 
the skin of the penis, scrotum, labia minora, eyelids, pinna, 
and beneath the nails. It contributes to the roundness 
and beauty of the body, besides acting as a storehouse for 
fuel against such times as the body cannot gain its proper 
nutriment from food, as in fevers. It also gives lodge- 
ment to the coil or sweat glands, and aids in protecting 
the underlying parts from injury. The lower ends of the 
deep hair follicles are also in this part of the skin. The 
subcutaneous tissue merges into the underlying fascia? of 
the muscles and the periosteum of the bones. Under the 
name of columnos adiposce J. C. Warren has described cer- 
tain prolongations of fatty tissue running up to the bases 
of the hair follicles. They are important in relation to 
the pathology of carbuncle. 

Blood Vessels. The arteries which supply the skin 
come up from below to form a horizontal plexus in the 
subcutaneous tissue, from which the vessels proceed per- 
pendicularly through the corium to form a second hori- 
zontal plexus just below the papilla?. From the lower 
plexus small branches pass to the fat-cells, sweat glands, 
and, according to Unna, to the hair papilla?. From the 
upper plexus branches are given off which enter the 
papilla? of the skin. There are also branches to the 
hair follicles, sebaceous glands, and the tissue of the 
corium itself. Papillse that give lodgement to a tactile 
corpuscle have no arterial twig. The veins follow the 
same course as the arteries, but, of course, in the oppo- 
site direction. 

Lymphatics. Lymph vessels are large in the subcu- 
taneous tissue, smaller in the upper part of the corium, 
and form plexuses. "Juice-spaces," filled with lymph, 
are found abundantly in the epidermis and papilla?, about 



22 GENERAL CONSIDERATIONS. 

the glands of the skin, and around the muscles of the skin 
and the connective-tissue bundles and fat-lobules. 

Nerves. The skin is provided with both medullated 
and non-medullated nerve-libers and motor and vasomotor 
nerves. We have learned already that non-medullated 
nerve-fibers have been traced between the cells of the 
epidermis, some terminating at, if not in, the nuclei of 
the cells. It may be roughly stated that the nerves fol- 
low pretty much the same arrangement as the blood ves- 
sels, forming a sort of plexus beneath the papilla? and then 
giving off branches to the vessels, to the tactile corpuscles, 
to the papillae, the hair follicles, the sebaceous and the sweat 
glands, and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are located 
in the papilla?. They are oval or round bodies, and their 
long axis runs longitudinally. Not more than one papilla 
in four is supplied with one of these corpuscles, even 
where they arc most abundant — on the end of the index 
finger. They are composed, according to Unna, of 
large, flat connective-tissue cells, which are placed one 
above the other like money-rolls, and take up between 
them the terminal branches of the medullated nerves, 
which on entering the bodies lose their medulla and 
finally end between the cells. The transversely striped 
appearance presented by the corpuscles is due to the swol- 
len lateral edges of the cells and the band-like nerve- 
fibers that here and there appear upon the surface. 

The corpuscles of Krause are located in the sensory 
mucous membranes. They are rounded in shape and 
bear a close resemblance to the Pacinian corpuscles in 
structure. 

The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and con- 
sist in a colossal swelling-out of the sheath of Schwann, 
forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, 
faintly filamentous cellular substance, through the axis of 
which passes a sensitive nerve. As the latter enters the 
corpuscle it loses its medulla, and either terminates in 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 23 

the corpuscle or passes through it to enter one or more 
corpuscles. These corpuscles are most abundant in the 
fingers and toes and the palms and soles. They are sup- 
posed to enable us to appreciate pressure or traction. 

Fig. 2. 




Hair in follicle. . (After Kaposi.) 

a. Follicle mouth . b. Neck. c. Arch of follicle, d. Outer, e. inner sheath of 
follicle, p. Hair papilla, m. Fat-cells, n. Erector pili muscle, ep. Epidermis. 
s. Mucous layer of epidermis, o. Skin papillae, t. Sebaceous glands. /.External, 
g. internal root sheath, h. Cortex of hair. k. Medullary canal. I. Hair root. 



Hair. The hair is an epidermic structure which grows 
from a nipple-shaped projection, the hair papilla, situated 
at the bottom of a deep, slender pocket or sac-like depres- 
sion in the skin which is called the hair follicle. Com- 



24 GENERAL CONSIDERATIONS. 

mencing at the papilla it is bulb-shaped. This part is 
called the bulb and fits over the papilla like a cap. On 
leaving the papilla the body of the hair is first called the 
root, and then as it becomes narrower the shaft. The 
diameter of the shaft rapidly decreases until, leaving the 
skin, it terminates in the point. A fully formed hair is 
hollow, its central cavity being called the medullary canal 
and filled with the medulla . This is composed of a col- 
umn of cells arranged in layers, one layer being superim- 
posed on another. The main substance of the hair is 
called the cortex, and consists of long, spindle-shaped 
epithelial cells flattened out into fine bands which run 
in the long axis of the hair. This part of the hair gives 
it substance and strength, and in it is placed the pigment 
that determines the color of the hair. The outer layer of 
the hair is called the cuticle. It corresponds to the epi- 
dermis and consists of flattened, non-nucleated, fully 
eornified cells which cover the hair like scales and over- 
lap each other like shingles. 

The hair follicle is located for the most part in the 
corium, but in some very strong hairs it reaches down 
into the subcutaneous tissue. It is always, excepting at 
the dorsal edge of the eyelids, placed at an angle to the 
skin, and is a permanent structure that is not removed 
when the hair is plucked. It is composed of three layers, 
which are derived from the corium as it dips down to form 
the follicle. Between the follicle and the hair is the 
root sheath, which is derived from the epidermis. It is 
composed of two layers, which are called the external and 
the internal root sheaths. The whole arrangement of the 
hair and its sheath may be graphically conceived by re- 
garding the hair as a blunt needle pressed against the skin. 
The needle would form the hair, the epidermis Mould form 
the root sheath, and the corium would be to the outside of 
all and form the hair follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers and 
toes, the glans penis, prepuce, labia minora, and the ver- 
milion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main varieties 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 25 

of hair : 1 . Long, soft hair, as of the head and beard. 

2. Short, stiff hair, as of the eyebrows and eyelashes ; and, 

3. Lanugo, or soft, downy, colorless hair that is scattered 
all over the surface of the body where the other varieties 
are not. 

Nails. The nails, like the hair, are epidermic struct- 
ures. They are placed on the extensor surfaces of the 
terminal phalanges of the fingers and toes. Their prox- 
imal end is called the root, under which is the matrix, 
from which they grow. On the way to their distal end 
they pass over the nail bed. This is separated from the 
matrix by a more or less convex and apparent line called 
the lunula. At their posterior and lateral margins they 
are imbedded in a fold of skin that is called the nail fold. 
At their distal extremity they are separated from the end 
of the finger or toe. They are formed by the matrix, but 
in passing over the bed they receive a certain amount of 
nourishment from it, and their cells become rapidly corni- 
fied. They are slightly curved from side to side, being 
convex above and concave below, and are marked with 
fine lines. The flesh beneath the nail is the same as the 
skin in general, though without subcutaneous tissue. The 
nail takes the place of the corneous and granular layers 
of the skin. It has been estimated that it takes from one 
hundred and eight to one hundred and sixty-one days for a 
finger nail to grow from the lunula to the free edge, the rate 
of growth being more rapid in summer than in winter. It has 
been noted that in a case of fracture of a limb the nails of the 
fingers &v toes may cease growing until the bone is well knit. 

Sebaceous Glands. (Fig. 1.) These glands are of 
the racemose variety, and are closely related to the hairs, 
from two to six being attached to each hair, emptying by 
their ducts into the upper third of the follicle. Each 
gland is composed of a number of acini that empty by a 
common duct. They are composed of a delicate, struct- 
ureless capsule, the membrana propria, which continues 
along the duct to merge into the hair follicles. This is 
lined with large, though short, cubical or cylindrical epi- 
thelial cells arranged in one or two rows. These are 
continuous through the duct with the cylindrical cells of 



26 GENERAL CONSIDERATIONS. 

the outer rout sheath of the hair ;ui<l of the skin. The 
interior of the glands is filled with fatty secretion. 
Around the glands passes the external layer of the hair 
follicle. These glands occur also on the vermilion border 
of the lips, the labia minora, and the glans penis and pre- 
puce, though in these locations there are no hairs. 

The function of the sebaceous glands is to oil the hair 
and skin, thus rendering them soft and supple, and giving 
luster to the hair. This oily secretion is produced by the 
cells, which, as they reach the central part of the acini, 
undergo fatty degeneration. The glands are largest in the 
nose, cheeks, scrotum, mons veneris, labia, and about the 
anus. 

Sweat Glands. (Fig. 1.) The sweat glands are simple 
coil glands that are located in the lower part of the corium 
and in the subcutaneous tissue. Their ducts ascend through 
the corium in a straight or wavy line to the interpapillary 
spaces, where they enter the epidermis. The cells lining 
the coil are simple cubical epithelial cells. These are 
seated upon muscular fibers ; and a connective tissue, the 
membrana propria, comes outside of all. An abundant 
network of blood vessels surrounds each gland and '•ends 
off branches to its interior. The glands are also richly 
supplied with nerves. The duct is made up of pavement- 
epithelium upon the membrana propria. When the epi- 
dermis i- reached the membrana propria is lost, and the 
further tract of the duct seems to be made by the sweat 
working its own channel up between the epidermic cells. 
The duct ends as a rounded aperture on the surface of the 
skin that is called a sweat pore. Unna teaches that the 
sweat produced by the coil glands is mixed with other 
elements while passing through the epidermis, so that the 
secretion that appears at the sweat pores is not the same 
as that which leaves the coils. He further teaches that 
the office of the coil glands is not to produce sweat, but to 
oil the skin. This theory still needs confirmation before it 
can be accepted as proven. His arguments have consid- 
erable weight, but space will not allow of their statement 
here. It has long been known that there was a certain 
amount of oil in the sweat. Sweat glands are most n inner- 



DTA GNOSIS. 27 

ous in the palms and soles. Their diameter is from 0.3 to 
0.4 mm. The largest are in the axilla?, where they have a 
diameter of 2 to 7 mm. and are very numerous. In the 
external meatus of the ear they secrete the so-called ear wax. 
Muscles. The skin is provided with muscles, both of 
the striated and unstriated variety. The striated muscles 
are found in the face and nose. The majority of the mus- 
cles of the skin are involuntary muscles. In the scrotum 
they run parallel with the raphe. On the penis and about 
the nipple their direction is circular. The arredores pi- 
lorum muscles are found all over the body, running in a 
more or less oblique direction from the bottom of several 
papillae down and around a sebaceous gland to be attached 
to the bottom of a hair follicle. By contracting they raise 
the hairs to a perpendicular position and aid in pressing 
out the contents of the sebaceous glands. 

Diagnosis. 

The Lesions of the Skin. We speak of primary 
and secondary lesions of the skin. By the first of these 
terms we mean the form assumed by the efflorescence at 
its first appearance. By the second of these terms we 
mean the subsequent changes the primary lesion undergoes 
of itself, or as the result of extraneous causes acting upon 
it. In running its course, whether influenced by treat- 
ment or not, almost every disease of the skin exhibits more 
than one lesion, and we can only speak of it as a macular, 
papular, or other disease from its most prominent and 
characteristic lesion. 

The primary lesions of the skin are the macule, the 
papule, the tubercle, the vesicle, the pustule, the bulla, the 
wheal, and the tumor. The secondary lesions of the skin 
are the crust, the scale, the excoriation, the fissure, the 
ulcer, and the cicatrix. These may be graphically repre- 
sented, following Piffard. 1 

Primary Lesions. A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from that of a pin-point to that of the palm of the 
1 Cutaneous Memoranda. Wood, N. Y., 1885. 



28 



G ENERA L CONSIDEBA TIOXS. 



hand, or larger. Large-sized and diffused, non-elevated 
lesions are usually spoken of as patches. A macule is 
usually round, but may be of any shape. It may be white, 
red, brown, black, blue, pink, or yellow, according to its 
cause. It may be due to hyperemia, as in erythema sim- 
plex ; to a change in the pigmentation of the skin, as in 
lentigo and chloasma, where there is increase of pigmen- 
tation, or in vitiligo, where there is decrease of pigmenta- 
tion ; to a hemorrhage into the skin, as in purpura ; to a 



Fig. 3. 

Primary. 



LESIONS OF THE SKIN. 



Fig. 4. 

Secondary. 



Papule 




^y 



Pustule • 
Bulla 

Wheal 



A r?\r~\ 




XXX 



Tumor 



development of blood vessels in the skin, as in naevus 
vascularis and telangiectasis; to a parasitic growth in the 
skin, as in chromophytosis ; or to a change in the consis- 
tency of the skin, as in morphcea and xanthoma. 

The macule may be evanescent or permanent ; may re- 
main as a macule during its existence, or may give place 
to a papule, vesicle, or pustule. It is the simplest of all 
the lesions of the skin, and is met with as a primary lesion 
of manv of its diseases. 



DIAGNOSIS. 29 

The principal macular diseases are chloasma, chromo- 
phytosis, erythema simplex, lentigo, melasma, inorphoea, 
naevus simplex and spilus, purpura, scleroderma, vitiligo, 
and xanthoma. 

A papule is a circumscribed, solid elevation of the skin. 
In size it varies from that of a pin-point to that of a split 
pea. It may be of different colors, but is usually some 
shade of red. It is soft or firm to the touch. In form 
it may be acuminated, rounded, flattened, or umbilicated. 
Its base may be round, oval, or angular. It may be due 
to inflammation, as in eczema ; to hypertrophy of normal 
structures, as in verruca; to the heaping up of epidermic 
cells about a hair follicle, as in keratosis pilaris ; or to the 
retention of sebaceous matter in a follicle, as in comedo 
and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed ; or it may change into a vesicle 
or pustule ; or it may soften and break down. 

Papular diseases have received the name of lichenoid 
diseases, and at one time we had a goodly number of 
lichens. Most of these have now been placed under other 
headings, as it is recognized that they are but single mani- 
festations of other diseases. Papular diseases are apt to 
be scaly and itchy. 

The principal papular diseases are : lichen tropicus, 
lichen ruber acum hiatus and planus, lichen scrofulosorum, 
lichen pilaris or keratosis pilaris, lichen urticatus or pap- 
ular urticaria, acne, comedo, milium, prurigo, and psoria- 
sis. Like the macule, the papule is found in many dis- 
eases that can not be classed as papular. 

A tubercle or nodule may be thought of as a large papule. 
Like it, it is a circumscribed solid elevation of the skin, 
usually of a reddish color. Indeed, the difference between 
a papule and a tubercle is mainly arbitrary and for con- 
venience. Thus, we speak of a solid lesion up to the 
size of a split pea as a papule, while above that it is 
spoken of as a tubercle. Some lesions which are usually 
spoken of as tubercles, such as the tubercular syphilide, 
may not be larger than a split pea. Quite commonly, 
when a lesion is larger than a cherry it is spoken of as a 



30 GENERAL CONSIDERATIONS. 

node. Auspitz 1 makes the distinction between a papule 
and tubercle on more scientific grounds, and regards a 
tubercle as a cell-infiltration into the corium. A tubercle 
is not only larger than a papule, but it extends deeper into 
the skin. In form and color a tubercle corresponds to a 
papule. 

Tubercles may be absorbed and disappear and leave no 
trace ; or they may break down and ulcerate and leave 
scars, as in syphilis ; or they may remain unchanged for 
an indefinite period, as in molluscum. 

The principal tubercular diseases are : carbuncle, epithe- 
lioma, keloid, lupus vulgaris, molluscum, rhinoscleroma, 
and xanthoma. Tubercles form a very prominent symp- 
tom in leprosy, syphilis, and erythema multiforme. Of 
course, tubercular used in this sense has nothing to do 
with the tubercle of tuberculosis. 

A vehicle is a circumscribed elevation of the epidermis 
that contains fluid, generally serous. In size it varies from 
that of a pinhead to that of a split pea. Its color is crystal- 
line when only serum is present, more or less opaque and 
yellowish when the serum is mixed with pus, and of a red- 
dish hue when blood is effused into it. It may be pointed, 
rounded, flattened, or umbilicated. Vesicles are in most 
cases due to inflammation, as in eczema. They may be 
due to simple serous effusion, as in erythema ; or to the 
retention of sweat, as in sudamina. They have around 
them, in many cases, a red halo. As a rule, vesicles are 
superficial elevations of the epidermis, and readily rupture 
and pour out their contents upon the skin, forming a 
yellowish crust. They may be below the mucous layer 
of the skin. They may remain as vesicles, and dry up, 
their contents being absorbed; or they may become 
changed into pustules. 

The principal vesicular diseases are : dermatitis venen- 
ata, dysidrosis, eczema, herpes, hidrocy stoma, impetigo 
contagiosa, sudamina, varicella, and zoster. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle. Its color is yellow and opaque; or brown or 
1 Ziemssen's Handbuch der Hautkrankheiten. 



DIA GNOSIS. 31 

reddish if there is an admixture of blood with the pus. 
It either originates as a pustule or develops from a vesicle 
or papule. As a rule, pustules are inflammatory, and 
when they appear as a general eruption, as in syphilis, 
they indicate a strumous or broken-down condition. 
Around each pustule there is very commonly a well- 
marked inflammatory areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish crust. If 
located deep in the skin, they may leave scars. 

The principal pustular diseases are acne vulgaris, ec- 
thyma, furunculosis, impetigo, and sycosis. Eczema, 
syphilis, and a few other dermatoses are often markedly 
pustular in character. Pustular diseases are often spoken 
of as impetiginous. 

A bulla, or bleb, may be considered as a large vesicle or 
pustule. It is of irregular oval shape or umbilicated. It 
may be as large as a split pea, or reach the size of a goose 
egg. It rises from the skin with a slight areola or with 
none at all. It is either fully distended or flaccid, and 
does not rupture readily. It may be a bulla from the be- 
ginning, as in pemphigus ; or it may be formed by the 
coalescence of two or more vesicles ; or it may arise on an 
erythematous lesion, as in erythema multiforme. Its con- 
tents are usually serous, but these may change in time to 
pus. 

The only purely bullous disease is pemphigus ; but bulla? 
are met with in dermatitis, dermatitis herpetiformis, ery- 
sipelas, erythema multiforme, impetigo contagiosa, leprosy, 
and syphilis. 

A wheal is an evanescent round, oval, or elongated flat 
elevation of the skin, of a pinkish or white color, which is 
more or less firm to the touch. It is surrounded by a red 
halo. It may be as small as a pea or as large as the palm 
of the hand. Wheals appear suddenly and disappear within 
a few hours. They are due to a spasm of the capillaries 
of a limited area of the skin and an effusion of serum into 
the meshes of the skin, the raised part being the site of 
the effused fluid, and the halo the congested vessels in the 
neighborhood. The whiteness of the wheal is due to the 



32 GENERAL CONSIDERATIONS. 

sudden effusion of the serum squeezing out the blood of the 
area. As the circulation becomes re-established the serum 
is absorbed, the whiteness changing to pink, and then to 
the normal color of the skin. The disease in which wheals 
are met with is urticaria. They can also be produced by 
contact with the stinging-nettle, or by sharp traumatism 
on skins predisposed to urticaria. 

A (amor is a new growth in the skin which projects more 
or less above its surface and dips down into the subcutane- 
ous tissue. It may be pedunculated. Tumors vary greatly 
in size. Their color is often that of the surrounding skin, 
but they may be red. They may become ulcerated. A 
tumor is rather a surgical than a dermatological lesion. 
Epithelioma, fibroma, and sarcoma are types of tumors. 

Secondary Lesions. The secondary lesions of the 
skin require a much less extended description. The main 
distinction to be retained in the student's mind is that be- 
tween a crust and a scale. This can be readily done if it 
is remembered that a crust is formed by the drying of 
some secretion or exudation upon the skin : while a scale 
is a dry, laminated mass of epidermis which has separated 
from the tissues below, the product of imperfect or per- 
verted nutrition. Thus, in vesicular eczema when the 
exudation dries on the skin we have a yellowish crust ; 
while in squamous eczema we have thin scales, the horny 
layer of the skin not being perfectly produced. Crusts 
are yellow when formed of dried serum, green when de- 
rived from pus, and black when there has been an admixt- 
ure of blood. Scales are whitish, grayish, yellowish, or 
dirty yellow. 

Crusts are especially characteristic of ecthyma, some 
forms of eczema, favus, impetigo, and seborrhoea. 

Scales are specially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ich- 
thyosis, and some of the lichens. 

Excoriations are familiar as scratch-marks. They are 
superficial denudations of the skin. They are of value 
as a sign of itching, as scratching is their chief, though 
not sole, cause. They frequently are followed by pig- 
mentation, if the irritation causing the scratching is long 



DIAGNOSIS. 33 

continued. They also occur as the natural result of some 
diseases, such as pemphigus, without the intervention of 
scratching. 

Fissures are cracks in the epidermis extending down to 
the corium. They are usually located in the folds of the 
skin, as over the joints. They occur in diseases attended 
by infiltration and thickening of the skin by which its 
elasticity is interfered with, and are especially seen in 
eczema, psoriasis, and syphilis. They often bleed, and 
sometimes are very painful. 

Ulcers are irregularly shaped and sized losses of sub- 
stance. They may be quite small or of very large size. 
They may be shallow, deep, excavated, or scooped out. 
Their edges may be undermined, as in tuberculosis ; everted, 
as in epithelioma ; or sharp-cut, " punched out," as in 
syphilis. Their secretion may be scanty or abundant. 
They result either from some previous lesion or from in- 
jury. They occur in carbuncle, chancre, chancroid, ec- 
thyma, varicose eczema, epithelioma, furuncle, lupus vul- 
garis, sarcoma, syphilis, tuberculosis, and sometimes after 
zoster, dermatitis, and some pustular eruptions. They 
always heal with a cicatrix, leaving a scar. 

Cicatrices, or scars, represent an effort of Nature to heal 
a damage to the skin by means of connective tissue. They 
occur only when the papillary layer of the skin or the parts 
beneath are destroyed. They may be depressed, as in 
smallpox ; raised and puckered, as in lupus ; smooth and 
white, as in syphilis. While ulceration usually precedes 
them, they occur independently of it, as in leprosy, sclero- 
derma, and atrophoderma. 

Other Elements of Diagnosis. Having mastered 
the lesions of the skin, we are now prepared to study the 
other elements of diagnosis. We must observe the loca- 
tion, distribution, and configuration of the eruption, and 
note its color, and whether or not it itches. When we 
have done all this, and have come to a probable conclusion 
as to the disease before us, then is the proper time to ask 
the patient a few questions as to his sensations and the 
duration of the attack. In a few cases of doubtful diag- 
nosis the microscope will aid uk 



34 GENERAL CONSIDERATIONS. 

Location. Upon the/«ce we meet with acne, comedo, 
chloasma, erythematous eczema, epithelioma, herpes febrilis, 
lupus vulgaris and erythematosus, milium, rosacea, sycosis, 
and xanthoma. 

An eruption confined to the middle third of the face, 
from above downward — forehead, nose, and chin — is in all 
probability rosacea. 

An eruption occupying the bearded portion of the face, 
above a line drawn from the angle of the mouth to the 
angle of the jaw, is probably sycosis. Should it occupy 
the bearded portion of the face below that line it is prob- 
ably trichophytosis barbae. 

If a scaly patch is found in front of the ear, it should 
put us on the lookout for psoriasis, which will often be 
found elsewhere on the body. This point may be useful 
in the diagnosis of a doubtful case. If a raw, or cracked, 
or scaly place is found behind the ear, it points to eczema. 

Upon the scalp we meet with alopecia, alopecia areata, 
eczema, favus, pediculosis capillitii, seborrhcea, and tricho- 
phytosis. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape of the neck, the case is prob- 
ably one of pediculosis ; and if we look for the nits, we 
shall find them either at the site of the eruption or over 
the parietal region. 

The chest is the favorite location for chromophytosis and 
keloid. 

Upon the bach we meet with acne, carbuncle, and the 
scratch-marks due to the irritation from pediculi. If 
we find long, parallel scratch-marks over the shoulder- 
blades, they are quite good evidence of pediculi in the 
clothing. 

The extensor surfaces of the forearms and wrists are the 
favorite sites of erythema multiforme, while the flexor 
surfaces give lodgement to lichen planus and scabies. The 
posterior surface of the elbow is a common location for 
psoriasis, while on the soft skin of the bend of the elbow 
avc find eczema. 

Upon the legs ecthyma, elephantiasis, erythema exudati- 
vum, purpura, and ulcei's are apt to occur. 



DIAGNOSIS. 35 

A general eruption is either one of the exanthematous 
fevers, dermatitis exfoliativa, eczema, erythema, ichthy- 
osis, lichen planus, lichen ruber acuminatus, pityriasis 
rubra pilaris, psoriasis, scabies, or syphilis. 

Of these, syphilis is most marked on the sides of the 
chest and abdomen, and upon the face along the margin 
of the hair. It may also be given as a general rule, 
to which there are many exceptions, that syphilis occu- 
pies the flexor surfaces of the extremities and the ante- 
rior plane of the trunk, while psoriasis is found most 
markedly upon the extensor surfaces of the extremities and 
the posterior plane of the trunk. 

Configuration. Certain diseases assume certain con- 
figurations, which, if noted, will sometimes assist in 
diagnosis. Thus we have 

The circular outline and scalloped border of syphilis. 

The round and bald patch of trichophytosis and alopecia 
areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum 
and the gumma of syphilis. 

The angular umbilicated papules of lichen planus. 

The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis, 
and seborrhoea corporis. 

The patches of grouped vesicles upon reddened bases 
located over the course of a cutaneous nerve in zoster. 

The Differential Diagnosis of Ringed Erup- 
tions. 1 The eruptions that appear, either habitually or 
occasionally, in ring shape are trichophytosis corporis, syph- 
ilis, psoriasis, erythema multiforme, seborrhoea sicca, pity- 
riasis maculata et circinata, and, rarely, favus of the body 
in its so-called herpetic stage. These eruptions often bear 
so strong a resemblance to one another that it is hard for 
even experts to make a positive diagnosis. It is, therefore, 
small wonder that the physician who has not had much 
experience in skin diseases should sometimes make an error 
in diagnosis. Happily, each one of them does have certain 
so well-defined features that a sure diagnosis can be made 
1 American Medico-Surgical Bulletin. 



36 GENERAL CONSIDERATIONS. 

in the great majority of cases. It is my desire to indicate 
the points in differential diagnosis between them. 

Trichophytosis, or ringworm, may be taken as the type 
of ringed eruptions. It must be clearly understood at the 
outset what is meant by an annular or ringed eruption. 
It is one that has a well-defined raised border surrounding 
a patch of skin that is normal or nearly so, or in which 
active disease has ceased. A circular patch, such as is 
seen in alopecia areata, is not a ringed eruption, as it does 
not present a well-defined raised border, and the whole 
patch is equally affected. In ringworm we have a well- 
defined, slightly raised border composed either of vesicles, 
rarely seen, or pustules, or papules that are slightly scaly, 
or of small crusts, the remnants of the vesicles or pustules. 
Inside of this ring the skin may show no change, or be 
slightly scaly, the scaliness diminishing toward the center. 
The eruption usually itches slightly. There may be only 
one patch, or several in different stages of development. 
If there is any doubt about the diagnosis, it will readily 
be cleared away by examining some of the scales under 
the microscope, when if it be trichophytosis the fungus 
will be found with ease. 

This form of ringed eruption differs from syphilis: in 
itching ; in having a narrow border made up of scales, 
vesicles, pustules, or crusts ; in its scaly center ; in being 
superficial, and in its microscopical characters. It differs 
from psoriasis : in its superficial character ; in its border 
not being covered with silvery scales ; in not being a gen- 
eral eruption ; in its parasite, and in not being of a pink- 
ish-red color. It differs from erythema : in not being a 
symmetrical eruption ; in its narrow border ; in its color, 
that can not be made to disappear under pressure, and in 
having a fungous growth as its cause. It lacks the greasy 
character of seborrhcea sicca, and differs from the latter 
also in the presence of the trichophyton fungus. It differs 
from pityriasis rosea : in not being a general eruption ; in 
its center being slightly grayish, and not of the appearance 
of chamois leather, and in being parasitic. 

Syphilis at times shows itself in rings. These have one 
striking negative character, and that is, that they do not 



DIAGNOSIS. 37 

itch nor burn. All the other ringed eruptions either itch 
or burn to a greater or less degree. Syphilis has a well- 
marked, rather broad, slightly elevated border, which is in- 
filtrated, raw-ham colored, and composed of either scaling 
papules or of nodules. The center of the ring may be 
normal, scaly, crusted, superficially or deeply cicatrized, 
reddened or pigmented. Sometimes the nodules of the bor- 
der may break down and ulcerate. Occurring on the palms 
or soles, the border may be hardly, if at all, elevated, but 
simply red and scaly. This is due to the thickness of the 
epidermis in these regions. It is quite characteristic of 
the annular syphilide that it is often an incomplete ring, 
the border being broken at some point. The diagnosis 
will be aided by finding other evidences of syphilis, which 
usually are to be found. This form of ringed eruption 
differs from ringworm in the way already indicated. As it 
is quite possible for a syphilitic subject to have any of the 
other ringed eruptions, a history of the case will sometimes 
be unreliable, if depended on for diagnosis. It is, there- 
fore, better to make the diagnosis solely on what we see. 
It is only in very doubtful cases that a history of the 
eruption is desirable to help us to decide aright, and then 
only after a careful weighing of the evidence. A ringed 
syphilide is most apt to be confounded with psoriasis, but 
it differs from it : in having a raw-ham, and not a pinkish- 
red, color ; in not itching ; in showing a red seam beyond 
the scales ; in the scales being less silvery, smaller, and 
more abundant ; in the border formed of individual lesions ; 
in not being so generally distributed over the body, and 
in not occurring in the characteristic sites of psoriasis — 
that is, on the elbows and knees. If the case were psori- 
asis, there would surely be some characteristic patches to 
guide us. Erythema multiform,e and syphilis are so un- 
like in every respect that it is hardly possible they could 
be confounded. Seborrhea corporis is located on the chest 
and between the shoulder-blades, and there will be found 
at the same time seborrhoea on the scalp. These locations 
are not characteristic of syphilis. Moreover, syphilis lacks 
the greasy feel of seborrhoea. The raw-ham color of the 
syphilide is never seen in seborrhoea. Pityriasis rosea is 



38 GENERAL CONSIDERATIONS. 

readily distinguished from syphilis by the occurrence at 
the same time of both macules and rings, by its lighter 
color, and by the chamois-leather look of the contents of 
the rings. The infiltrated border of the syphilide dis- 
tinguishes it from all the other ringed eruptions. 

\Vhen psoriasis forms rings it does so by the clearing 
up of the centers of old patches, and there will be char- 
acteristic patches of psoriasis to guide us in diagnosis. 
The border of the ring is usually quite broad and slightly, 
if at all, thickened ; its color is the pinkish red of psoria- 
ris, and the scales that cover it are large and silvery. 
The center of the ring is composed of normal skin, which 
may be a little red. The scaling will be seen to be com- 
mensurate with the redness. The disease is commonly 
itchy. 

The differential diagnosis from syphilis and ringworm 
has been given above. Like the syphilide, psoriasis bears 
no resemblance to erythema except in its ring shape. 
From seborrhea it differs in not being greasy and in its 
silvery scales. At times the two diseases do bear a close 
resemblance to each other, but even then it will usually be 
easy to find some typical lesions of one or the other disease 
to decide the matter. There is little likelihood of confound- 
ing psoriasis with pityriasis rosea., as the former is much 
less superficial than the latter, and its scales are large and 
silvery, and not small and adherent ; besides, it lacks the 
chamois-leather color which is a marked feature of pityri- 
asis rosea. 

Erythema multiforme, or erythema exudativum, not in- 
frecpjently forms rings by the absorption of the centers of 
large tubercular lesions or patches. It is easy to recognize 
the lesion, as there will be other and characteristic erythe- 
matous lesions to guide us. The border of the ring is 
raised and its color is red, the redness, as in all erythe- 
matous lesions, being readily made to disappear on press- 
ure, to return promptly when the pressure is removed. 
When the lesion has lasted for some time the color be- 
comes darker and cannot so readily be made to disappear, 
because now the coloring-matter of the blood remains be- 
hind in the tissues. The center of the ring is red or 



DIAGNOSIS. 39 

discolored on account of the partially absorbed exudate. 
Another form of ringed erythema is what is known as 
erythema, or herpes, iris, in which we have either a pur- 
plish spot surrounded by a raised whitish ring containing 
fluid, and outside of this a red areola ; or a vesicle in the 
center with a purplish zone about it, a raised whitish ring 
containing fluid, and a red areola outside of all ; or a 
central bulla with one or two rings of vesicles about it. 
This form of erythema is usually symmetrical, and occurs 
upon the extensor surfaces of the arms and legs and upon 
the backs of the hands and feet. It may occur as part of 
a general erythema multiforme or by itself. The ringed 
erythema is so peculiar in its features as to offer little 
difficulty in differential diagnosis, and need not detain us 
further. 

Seborrhcea sicca, or seborrheal eczema, as it is now 
called, is the lichen annulatus of Wilson and the sebor- 
rhea corporis of Duhring. It forms ring-shaped lesions 
on both the scalp and trunk. These are best and most 
often seen on the trunk, but may also be found on the 
limbs. Their favorite sites are the chest and the back 
between the shoulder-blades. The rings are of large and 
small size, and at the same time there will be found fatty 
plates with more or less redness, the usual lesions of seb- 
orrhoea sicca. The border of the ring may be broad or 
narrow. If the former, then it will be formed of greasy 
crusts upon a reddened base ; if the latter, the border will 
be seen to be made up of a number of red points, the 
open mouths of the follicles of the skin ; or the border 
may be narrow and yet made up of fatty crusts. The 
skin in the neighborhood is commonly greasy, and the en- 
closed area of skin will look as if varnished, being glazed 
and yellow. 

The differential diagnosis from ringworm, syphilis, and 
psoriasis has been given already. The greatest difficulty 
is often found in the diagnosis from pityriasis rosea, es- 
pecially when the ringed lesions are on the legs. The 
resemblance is then so great that it has led some to 
question if seborrhoea and pityriasis are not identical. As 
a rule, the seborrheal lesion is more fatty and yellow, while 



40 GENERAL CONSIDERATIONS. 

that of pityriasis is more scaly, and the contained skin is 
more wrinkled and chamois-leather-looking. In typical 
cases there will be no difficulty in the diagnosis if the 
characteristics of both diseases are borne in mind. The 
presence of a seborrhcea on the scalp is corroborative evi- 
dence of the seborrheal nature of a doubtful eruption. 

Pityriasis rosea, or pityriasis maculata et circinata, not- 
only shows rings, but also, as its name indicates, macules, 
and both forms of lesions are always present at the same 
time. It can easily be seen that the primary lesion is a 
pale-red papule, increasing in size, to become later a rosy- 
red lesion, which, after attaining a certain size, clears up 
in the center, so as to form a ring with a pale-red border 
and a yellow, old-parchment, or chamois-leather-like cen- 
ter. Both the borders and inclosed areas are slightly 
scaly. It is usually most pronounced on the chest and 
shoulders, but it may be a general eruption, though the 
hands, feet, and face are rarely aifected. Its differential 
diagnosis has been given under the previously described 
diseases. 

It is a property of all these eruptions that, if two or 
more of their rings appear near each other, they are very 
apt to run together and form figure-of-eight or gyrate 
lesions from the disappearance of the borders at the part 
where contact has taken place. 

The ring-shaped or herpetic form of favus is not com- 
monly seen. It occurs in favus of the body. It will 
then bear so strong a resemblance to ringworm that at 
first it is impossible to distinguish which it is ; but it is 
only necessary to wait a short time, when a well-marked 
favic cup will develop. 

Lichen planus papules, when they have crowded together 
into a patch, will form rings at times by the absorption of 
the central papules. The ring is rarely of large size ; its 
color is the peculiar violaceous color of lichen planus ; the 
center is depressed and the whole is scaly. As these rings 
are never seen apart from the simultaneous occurrence of 
characteristic flat, angular, smooth papules, with central 
umbilication, there is no possibility of confusing them with 
those of the other ringed eruptions. 



DIAGNOSIS. 41 

We occasionally see rings in lupus erythematosus and 
in epithelioma, but such occurrences are exceptional. 
When they do occur the other signs of the one or the 
other disease will be so much in evidence that there will 
be little danger of mistake in diagnosis. 

Lupus erythematosus has a peculiar red color ; its border 
is usually covered with closely adherent scales, and the 
ring will have a cicatricial center. At the same time 
there will be other patches present of typical lupus ery- 
thematosus. 

Epithelioma, even when it does form a ring, has that 
characteristic hard, raised, waxy border which we see in 
all epitheliomas of the skin, and that will be enough for 
diagnosis. 

Color. An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea of 
the color of an eruption, but perhaps this list may prove 
helpful : 

Raw ham of syphilis. 

Brilliant red of erysipelas. 

Inflammatory red of eczema. 

Dark red of purpura. 

Bright red of psoriasis. 

Brown of pigmentary diseases. 

Sulphur yellow of favus. 

Buff of xanthoma. 

Violaceous or dull red of lichen planus and lupus 
erythematosus. 

White of leucoderma. 
History. Having carefully noted all these objective 
symptoms, we have, by this time, pretty well made up our 
minds as to the diagnosis of the case. Now is the time 
to obtain the history of the case, either for the purpose of 
scientific study of its etiology and natural course, or for the 
purpose of clearing up some doubt as to the diagnosis. It 
is so easy to obtain a history of syphilis that were we influ- 
enced by the history we would be often misled. There is 
no reason why a patient with syphilis should not have any 
other skin disease. Moreover, most people do not pay 
much attention to the course of their diseases, and it would 



42 GENERAL CONSIDERATIONS. 

be difficult for them to give a correct account of them if 
they would. Of course, a clear history of the initial 
lesion of syphilis, or its presence, would clear up any 
doubt as to an erythematous rash. The history of a scaly 
disease recurring at frequent intervals upon the elbows and 
knees would go far to determine the existence of psoriasis. 
In urticaria we often have to rely upon the statement of 
the patient or attendant as to the appearance of the wheals, 
as their presence at some time is pathognomonic, and they 
are usually absent when we see the patient. In these 
and similar ways the history is useful, but it should be 
entirely subordinated to the study of the objective symp- 
toms. 

Pruritus. It is important to know whether a disease 
itches or not. This we can discover by the presence or 
absence of scratched papules or scratch-marks. The itch- 
ing eruptions are dermatitis herpetiformis, eczema, pedicu- 
losis, prurigo, pruritus cutaneus, scabies, and urticaria. 
The symptom is also present in the lichens, psoriasis, 
seborrhcea, and trichophytosis. It is markedly absent in 
syphilis, though an occasional case of syphilis will be 
encountered in which there is itching. 

Burning. The sensation of burning is one the exist- 
ence of which we must take upon the patient's statement. 
It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches, but if you watch 
him he will soon begin to rub his skin gently with the 
heel of his hand. This indicates that the sensation is one 
of burning and not of itching. In itching, the nails are 
used, or else the rubbing is vigorous. 

Pain. Another symptom for the establishment of which 
we have to rely upon the patient is that of pain. The 
vast majority of skin diseases, while they may cause more 
or less discomfort, are not painful ; but sharp neuralgic 
pain is a prominent symptom in epithelioma and zoster. 
The presence of pain of a shooting character will be 
one point in the differential diagnosis between lupus and 
epithelioma, and in favor of the latter. We also meet 
with pain in neuroma, dermatalgia, and in some forms of 
leprosy 



DIAGNOSIS. 43 

Microscope. The principal use of the microscope in 
the hands of the general practitioner is, as far as derma- 
tological diagnosis is concerned, the determination of the 
presence or absence of fungi in hair and scales in a doubt- 
ful case of ringworm, favus, chromophytosis, or other 
parasitic disease. Happily, as between favus and ring- 
worm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 
In the hands of the skilled pathologist and bacteriologist 
the microscope is constantly adding to our knowledge of 
diseases of the skin and is of great value. 

A few words must be said about the methods of examina- 
tion of patients. They should be always examined by day- 
light or by electric light. It is prudent to refuse to give 
an opinion of a case when seen in a poor light or by arti- 
ficial light. If the patient is a man, it is necessary to 
request him to strip from top to toe, if there is the slight- 
est need of seeing more than the ordinarily exposed parts. 
In the case of a woman such an inspection can seldom be 
made. The same end can be attained by exposing one 
part after another. In all cases we are justified in refusing 
to treat a case that we have not been given ample oppor- 
tunity to examine. 

All examinations of patients should be made in a warm 
room. The contact of cold with the usually covered skin 
is apt to give it a mottled look that obscures the diagnosis. 
It is well never to give a diagnosis of an obscure case that 
is under local or constitutional treatment until all treat- 
ment has been suspended for a few days and the disease 
allowed to assume its natural appearance. 

Under the name of diaskop TJnna has recommended the 
use of a small piece of thick, clear glass, marked with a 
measuring-scale, for the purpose of exercising pressure 
upon the skin under examination. This does aw T ay with 
the confusing redness, brings into greater prominence ana- 
tomical lesions, and enables us to take accurate measure- 
ments of them. 

Every patient should be regarded as possibly out of 
health in some way quite apart from his skin trouble, and 
examined as to the performance of all his bodily functions 



44 GENERAL CONSIDERATIONS. 

quite as carefully as if he had come to us only for the 
treatment of some internal disorder. 



Therapeutic Notes. 

In the second part of this book will be found the treat- 
ment suitable to the various diseases. In this place my 
object is to give the reader a few notes upon some of the 
newer and comparatively unknown remedies for skin 
diseases. 

Liquor gutta perchce (traumatical) and flexible collodion 
are not new remedies, but are not as well known as they 
should be. Their advantages are that they are not greasy, 
prevent the clothing from being soiled, give us a fixed 
dressing, and exert a certain amount of pressure upon the 
skin that is useful in some cases. They are most used in 
the treatment of psoriasis, ringworm, and in circumscribed 
chronic diseases. Drugs suspended in them are not as 
active as when exhibited in ointments. In acute diseases, 
and specially where there is more or less exudation, they 
can not be used. 

Plaster-muslins were devised by Unna. They are made 
by spreading upon muslin a mixture of gutta percha and 
oleate of alum. With the plaster mass many drugs may 
be combined. Salve-muslins we owe also to Unna. They 
consist of a salve mass composed of benzoated mutton 
tallow and wax, with which various drugs are combined. 
The muslin is dipped into the melted mass, then dried 
and rolled flat and smooth, either on one or both sides. 
Machinery is used for the purpose. 

Pastes answer admirably for the acute and exudative 
conditions, as they protect the part and at the same time 
allow the exudate to work up through them, and thus 
escape. Lassar's paste, composed of zinc oxide, starch, 
and vaseline, as set forth in the formulary at the end of 
this book, was one of the first of these, and is still prob- 
ably more used than any of them. Various other pastes 
have been proposed. It is found that infusorial earth 
(Kieselguhr) added to any ointment in the proportion of 
10 per cent, will form a good paste. 



THERAPEUTIC NOTES. 45 

Salve pencils and paste pencils we owe to Unna. The 
former are composed of wax and olive oil moulded into 
sticks about the size of the little finger. The latter are 
made of starch, tragacanth, or gum arabic, with which the 
drug is incorporated into sticks about the size of a slate 
pencil. Neither form of pencil has come into general use. 

Gelatin preparations, one of which is given in the for- 
mulary, were introduced as preferable to ointments, and 
many German and English authorities speak well of 
them. They are troublesome to apply because they have 
to be heated before being used. They have not become 
popular in this country. The best one, in my experience, 
is that devised by Unna, made of oxide of zinc, 30.; 
gelatin, 30.; glycerin, 39.; and water, 10. This when 
cold forms a solid mass like white rubber. It is best 
used by heating it in a double saucepan like that used 
for cooking oatmeal. When warm it is to be spread on 
with a wide painter's brush. Immediately over the layer 
thus formed place a layer of absorbent cotton and then a 
roller bandage. It is excellent in subacute and chronic 
eczema. 

Under the name of skin splints Unna and Engman l have 
introduced a method of applying dressings in skin diseases 
that is certainly ingenious. Pressure is often wanted. It 
should be even. It is also desirable that such dressings 
should be durable, not readily dislodged, and easily re- 
moved and replaced. For this purpose the part to be 
dressed is first covered with a layer of plaster- or salve- 
muslin, or simple bandage-muslin. This is painted over 
with a preparation composed of gelatin and glycerin, of 
each 1 5 parts ; water, 40 parts ; and oxide of zinc, 30 
parts. When this is set it is painted over with a 10 per 
cent, solution of chromic acid, the green color of which 
may be masked by applying a varnish of zinc oxide and 
shellac. If a hairy part is to be dressed, and it cannot be 
shaved, the hairs should be greased. To remove the 
dressings it is only necessary to raise the edge and to 
touch the under side of the plaster with absorbent cotton 
wet with benzine. Variously medicated salve- or plaster- 
1 Monatshefte f. prakt. Dermat., 1893, xvii., p. 481. 



46 GENERAL CONSIDERATIONS. 

muslins are to be used according to the nature of the 
ca^c. 

George H. Fox 1 has brought out a series of elastic web- 
bing, broad rings of various sizes, that are admirable for 
retaining dressings in place. They serve the purpose of 
Unna's skin splints without any trouble either to the pa- 
tient or physician. 

In 1891 two excellent excipients were brought to our 
notice : one that is made from gum tragacanth, and called 
bassorin ; and one that is made from Irish moss, and 
called plasment. They both sink well into the skin, leav- 
ing a protective film on it that can be readily removed 
with water. A more recent excipient of this class i> called 
gelanthum. It is composed of gelatin and tragacanth. 

Medicated soaps, specially those containing an excess 
of fat, have been brought out in great variety during the 
past years, and possess certain virtues, though as a rule a 
soap is not the best vehicle for medication. They are 
cleanly, can be readily removed from the skin with Mater, 
and can be made to produce a greater or less effect accord- 
ing to whether the lather is allowed to remain or not. 

Under the name of oleum physeteris or chcenoeeti, a 
species of whale oil was recommended by Guldberg 2 as 
an excellent excipient. Altlial 3 is also derived from 
whale oil, in this case the Walrat whale. It is said to be 
odorless and perfectly bland. It occurs as mother-of- 
pearl white crystals, which subjected to heat form a fatty- 
feeling mass. Oleic acid is another vehicle that poss 
the virtue of penetrating the skin. Lanolin and agnine, 
derived from wool fat, are among the newer greasy appli- 
cations that are supposed to penetrate the skin. Both 
possess a peculiar odor, unpleasant to many. This is 
most marked in lanolin. It can be masked by combining 
with other ointments and by perfumes, such as rose water. 
Adeps lana is another of the newer bases for ointments. 
It is -aid to bf unirritating, and to be capable of taking 
up 300 per cent, of water without losing its salve-like 

1 New York Med. Journ., 1895, lxii.. p. 594. 
' Monatshefte f. prakt Dermat, 1890, x., 437. 
3 Deriuat. Zeitschrift, 1899, vi., 158. 



THERAPEUTIC NOTES. 47 

consistence. (Esypus, a refuse-product obtained in cleans- 
ing sheep wool, belongs to the same class of remedies. It 
is a disagreeable-looking stuff with a bad odor, and will 
not come into favor in this country. The property of 
penetration is not a virtue in all cases by any means, as 
in very many of our cases we wish to provide merely pro- 
tection. 

Resorbin is a mixture of almond oil, wax, water, and a 
small amount of a solution of gelatin. It combines readily 
with fats. It is commended for its penetrating powers, 
and is said to cool the skin and allay itching and inflam- 
mation. It is used alone and as an excipient in many dis- 
eases of the skin. 

Myronin is a yellow, slightly aromatic, butter-like sub- 
stance, for which penetrating powers are claimed. It is 
said to be a good excipient for mercury when used for in- 
unctions and for zinc oxide in intertrigo and dry eczemas. 

Vasogen is an oxidized vaseline which occurs both as a 
solid and a fluid, and is used as an excipient for various 
drugs. 

In the way of drugs of comparatively recent date we 
have : 

Airol, a combination of bismuth, iodine, and gallic acid, 
of gray-green color, odorless and tasteless, which is sup- 
posed to have the virtues of iodoform, though not so 
strong. It can be used as a dusting powder or as an oint- 
ment with vaseline. 

Alumnol is a fine white powder, non-hygroscopic, and 
stable. It is soluble in water to the extent of 45 per cent., 
forming a permanent solution. Used as a powder (12 to 
25 per cent.), ointment (1 to 12 per cent.), or in collodion 
(5 to 10 per cent.), it is recommended in acute and chronic 
eczema, various dermatitides, trichophytosis, chromophy- 
tosis, and contagious impetigo. 

Anthrarobin was proposed as a substitute for chrysa- 
robin, but it is a weak preparation and has not proved of 
special use. 

Aristol is a good dressing for ulcers used in the form of 
a powder. It is expensive, but a good substitute for iodo- 
form in some cases, as it is devoid of odor. In 10 per 



48 GENERAL CONSIDERATIONS. 

cent, strength it has been commended in the treatment of 
pson tsis, erysipelas, hyperidrosis, eczema, acne, rosacea, 
and all sorts of ulcers. 

Oreolin, in 1 to 5 per cent, solutions in water, is often 
useful id erysipelas, dermatitis, and as an antiseptic. It 
is very irritating to some skins. 

Dermatol, a subgallate of bismuth, is said not to cake 
and not to be poisonous. It is used as a powder for recent 
wounds, forming a crust under which healing takes place. 
For excoriations, intertrigo, and slightly moist eczema it 
is to be mixed with equal parts of starch. For large, 
irritable ulcers it may be used as an ointment of 10 per 
cent, strength or as a powder. 

Eigon is a combination of iodine and albumen. It 
occurs as a light-brown, tasteless, insoluble powder. It is 
used locally as a 20 per cent, powder or a 5 per cent, oint- 
ment in wounds and ulcers of all sorts. 

Envoi is a soft, impalpable powder of delicate pink hue. 
It is analogous to fullers' earth. It softens hard water 
when added to it, and with warm water forms a natural 
soap, leaving the skin feeling pliable and soft. It is said 
to be a good dusting powder and to possess remarkable 
power in separating and causing to fall horny patches of 
eczema and keratosis. For this purpose it is made into a 
paste with water, and, when applied, it is covered with 
oiled silk or rubber tissue. 

Europhen. An amorphous powder of yellow color and 
aromatic odor, containing 28 parts of iodine in 100. It is 
insoluble in water and glycerin; readily soluble in ether, 
chloroform, collodion, and traumaticin. It is useful in 
venereal ulcers and mucous patches in pure powder or 2 to 
5 per cent, ointment : also in tertiary syphilis as hypo- 
dermic injections in the vicinity of the lesion and in solu- 
tion in oil. 

Fllmogen is a solution of nitrate of cellulose in acetone 
with enough oil to make it elastic. It is used as an ex- 
cipient for salicylic acid, resorcin, iodoform, pyrogallol, 
bichloride of mercury, chrysarobin, tar, ichthyol, and car- 
bolic acid. It holds in suspension sulphur and zinc. 

Fuchsine, and other aniline dyes, in 1 per cent, solution 



THERAPEUTIC NOTES. 49 

in water, are recommended as useful in ringworm, inopera- 
tive cancerous ulcers, erysipelas, and other local infectious 
diseases. 

Gal/acetophenone, made by the action of acetic acid upon 
pyrogallol, was brought out in 1891 as remarkably effi- 
cient in the treatment of psoriasis. It may be used in 5 
to 10 per cent, strength in ointment or collodion, does not 
stain the clothing, and thus far has proved neither poison- 
ous nor very efficacious. 

Hydroxylamine is poisonous when absorbed. It was 
commended for psoriasis, but can not be used over large 
surfaces. It has been commended in lupus vulgaris and 
ringworm of the scalp and beard, a grain and a half of 
the hydrochloride being dissolved in an ounce and a half 
each of alcohol and glycerin. It has not gained popular 
favor. 

Ichthalbin is a combination of ichthyol and albumen. 
It is tasteless and odorless and usually does not- disturb 
digestion. It passes through the stomach unchanged, to 
be split up in the intestinal tract. Used internally in 
doses up to 60 grains a day in rosacea, eczema, urticaria, 
and pruritus. 

Ichthyol, especially the ammonio-sulphate, is useful, ac- 
cording to its introducer, Unna, and many others, both 
for external and internal use in rosacea, acne, eczema, 
urticaria, erythema, herpes, dermatitis herpetiformis, seb- 
orrhea, furunculosis, erysipelas, psoriasis, sycosis, lupus, 
and some other dermatoses. By the mouth it is best 
exhibited in capsules, from 3 to 15 drops being given 
during the day. Externally it is exhibited in solution 
in water or in paste-form, and in the strength of 2-| to 10, 
20, or 50 per cent. In a watery solution of 50 per cent, 
strength it is of the greatest value in the treatment of 
erysipelas. 

Iodolen is a combination of albumen and iodine, con- 
taining 36 per cent, of the latter. It is a yellow, coarsely 
granular, tasteless and odorless, almost insoluble powder. 
It can be given by the mouth as a substitute for the iodides 
and in the same doses as potassium iodide. Externally it 
is said to be a good, unirritating antiseptic. 

4 



50 GENERAL CONSIDERATIONS. 

Liquor anthraeis simplex and composifus are thin fluids 
prepared from coal tar, which are said to be non-poison- 
ous and to be useful in chromophytosis, trichophytosis, 
and chronic eczema. The compound fluid contains sul- 
phur, resorcin, and salicylic acid. 

Naftalan is a dark-colored, empyreumatic, thick mass 
that comes from Armenia. It is exhibited in ointment 
in the strength of 2h to 5 per cent. It seems to be useful 
in all diseases in which tar is indicated, but is more dis- 
agreeable to use. 

Xaphtol, or beta-naphtol, is another of the coal-tar de- 
rivatives, and is useful in seborrhceal dermatitis, scabies, 
and other diseases. 

Nosophen is a yellowish, odorless, and tasteless powder 
used as a dusting powder in ulcers, balanitis, herpes pro- 
gen italis, and wounds. 

Oxynaphthoic acid is recommended by Schwimmer for 
scabies and prurigo in 10 per cent, strength in ointment. 
His ointment for scabies is composed of 10 parts each of 
this acid, chalk, and green soap, to 80 or 100 parts of 
lard. 

Resorcin is recommended for seborrhoea capitis, begin- 
ning at 2 per cent, strength and increasing up to 5 or 10 
per cent, as the acute stage lessens; for psoriasis, 10 to 20 
percent. ; eczema about the mouth, 2 per cent. ; erysipelas ; 
and as a plaster for keloid and malignant growths. Strong 
preparations, say 20 to 30 per cent., can be used in acne 
and rosacea for the purpose of producing a dermatitis, to 
be followed by peeling off of the old skin, and in 40 per 
cent, strength it is one of the best remedies for lupus 
erythematosus. It must be remembered that this 
drug in weak strength promotes cornification, while in 
strong solution it macerates the skin. Remedies of 
this class are called "reducing" agents, and to them be- 
long sulphur. 

Sapolan contains 2| per cent, of a specially distilled 
naptha product, 1J per cent, of lanolin, and 3 to 4 per 
cent, of soap. It is of dark-brown color, of ointment con- 
sistency, smells slightly of naptha, and is easily rubbed 
into the skin. It is said to be very efficacious in acute and 



CLA SS1FICA TION. 5 1 

chronic eczema, pruritus senilis, impetigo contagiosa, ec- 
thyma, and urticaria. 

Sttrfeol is an antiseptic varnish composed of gum lac, 
benzoin, balsam of tolu dissolved in alcohol, and a small 
amount of carbolic acid or phenol. It is recommended 
especially because it adheres to the mucous membrane as 
well as the skin, and has been found useful in various 
ulcers and in chronic eczema. 

Tar. Compound tincture of coal tar is commended by 
Duhring as a substitute for liquor carbonis detergens. It 
is made by digesting 1 part of coal tar with 6 parts of 
tincture of quillaja (1 to 4 in 95 per cent, alcohol). It is 
used diluted, 15 minims to the ounce of water. 

Thilanin is lanolin acted on by sulphur and containing 
3 per cent, of the latter. Recommended for acute and 
chronic eczema, and in lupus erythematosus. 

Thiol, which is miscible with water, and is used in the 
strength of 20 per cent, in liquid or powder form, is said 
to be useful in seborrhoea, rosacea, acne, eczema, burns, 
pemphigus, dermatitis herpetiformis, impetigo, and zoster. 
It is a chemically prepared imitation of ichthyol. As it 
is free from the disagreeable odor of the latter drug, it is 
preferable to it in some cases. 

Thiosavonale is a readily soluble sulphur soap. 

Tumenol in solution with equal parts of ether, alcohol, 
and water, or glycerin, or in form of paste or ointment is 
useful in moist eczema, burns, sycosis, ulcers, and rhagades. 

Xeroform is a smooth, fine, greenish-yellow, tasteless 
powder, smelling faintly of carbolic acid. It is antiseptic, 
and is said to be useful in moist eczema of the hands and 
about the anus. 

Classification. 

In the present state of our knowledge it is impossible to 
make a satisfactory classification of skin diseases. Many 
attempts have been made to do this, and are still being 
made. Nearly every systematic writer tries his hand at 
it, with more or less indifferent success. One of the most 
scholarly classifications is that by Prof. E. B. Bronson, 1 
1 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 369. 



52 GENERAL CONSIDERATIONS. 

which is founded on that of Auspitz. Hebra's classifica- 
tion modified is found in a great many text-books. The 
arrangement of this book does away with classification. 
The one here given follows that given by Crocker, and has 
proved itself, after a number of years of use, a practical one. 

CLASSIFICATION AND NOMENCLATURE. 

Class 



I. 


HYPEREMIA. 


II. 


EXUDATIONES. 


III. 


HEMORRHAGIC. 


IV. 


HYPERTROPHIC 


V. 


ATROPHIC 


VI. 


NEOPLASM AT A. 


VII. 


NEUROSES. 


nil. 


MORBI APPENDICIUM. 


IX. 


PARASITE 



Class I. HYPEREMIA— CONGESTIONS. 

3[os( prominent primary lesion. 
rthema simplex. Erythema. 

" pernio. " 

" intertrigo. 

" scarlatiniforme. 
" fngax. " 

" roseola. 



Class II. EXUDATIONES— INFLAMMATIONS. 

Moat prominent primari/ lemon. 
Erythema exudativum multiforme. 

a. papillosum. Erythema and papules. 

/>. taberculosnm. " " tubercles. 

c. circinatum. " " vesicles. 

el. hullosum. " " bulla*. 

e. nodosum. " " nodes. 

/. iris. " " vesicles. 

Pellagra. 
Acrodynia. 

Urticaria. Wheals. 

E zema. Multiform lesions. 

ei. crythematosiim. 

h. papillosum. 

c. vesieulosnm. 

-/. pustulosum. 

e. rubrum, sew madidans. 

/. srpiamosum. 

7. verrucosum. 
Dermatitis seborrlioica. Redness and scaling. 



CLASSIFICATION. 



53 



Dermatitis repens. 

Impetigo. 
Ecthyma. 
Pompholyx. 
Herpes. 

a. facialis. 

6. progenitalis. 
Zoster 
Pemphigus. 

a. vulgaris. 

b. foliaceus. 
Epidermolysis. 
Equinia. 

Hydroa, seu Dermatitis herpeti- 
formis. 
Impetigo herpetiformis. 
Dermatitis. 

a. calorica. 
6. traumatica. 

c. medicamentosa. 

d. venenata. 
Dermatitis epidemica. 
Psoriasis. 

Pityriasis rubra, seu Dermatitis ex- 
foliativa. 
Pityriasis rosea. 

Lichen scrofulosorum. 

" pilaris. 

" planus. 

" ruber. 
Pityriasis rubra pilaris. 
Prurigo. 

a. mitis. 

b. ferox. 
Furnnculus. 
Carbunculus. 
Abscess. 

Pustula maligna. 
Ulcus. 
Erysipelas. 

Conglomerative pustular folliculitis. 
Dermatitis gangrsenosa. 



Most prominent primary lesion. 
Epidermic denudation and fluid ex- 
udation. 
Vesicles and pustules. 
Large vesicles and pustules. 
Bullae and vesicles. 
Grouped vesicles. 



Grouped vesicles. 
Bulla?. 



Bulla?. 
Multiple lesions. 

Grouped multiform lesions. 
Grouped pustules. 
Multiform lesions. 



Erythema and papules. 
Scaly crusts on red base. 

Diffuse redness with large scales. 
Oval, scaly, red patches, with yel- 
lowish center. 
Papules, grouped. 

" follicular. 

" flat, angular. 

" acuminate, scaly. 

" lenticular. 



Phlegmonous. 



Loss of substance. 

Erythema with brawny swelling. 

Patches of aggregated pustules. 

Gangrene. 



Class III. HEMORRHAGING— HEMORRHAGES. 
Blood extravasation. 



Purpura. 

a. simplex. 

6. hsemorrhagica. 

c. rheumatica. 
Scorbutus. 



Blood extravasation. 



54 



GENERAL COSSIDERA TIONS. 



Class IV. HYPERTROPHIC— HYPERTROPHIES. 





Parts affected. 


Ichthyosis. 


Epidermis and papillae. 


Keratosis pilaris. 


Papules about hair follicles. 


Acanthosis nigricans. 

Verruca. 

Porokeratosis. 


Epidermis and papillae. 


u 


Clavus. 


<< (( « 


Cornu cutaneum. 


" " " 


Callositas. 


" " " 


Tylosis. 


Epidermis. 


Scleroderma. 


Corium. 


Morphoea. 


"' 


Sclerema neonatorum. 


" 


Oedema 


" 


Elephantiasis. 


Whole skin. 


Acromegaly. 




Chloasma. 


Pigment. 


Lentigo. 


" 


Nsevus pigmentosus. 


" 



Class V. ATROPHIA— ATROPHIES. 



Albinismus. 
Leucoderma. 
Atrophia cutis propria. 
Atrophoderma senilis. 

" striatum et macula- 

turn. 
Atrophoderma pigmentosum. 
Ulcus perforans. 
Ainhum. 



Parts affected. 
Pigment, deficiency, disturbance. 

Corium. 



Class VI. 

Keratosis follicularis. 

Molluscum 

Colloid Degeneration 

Xanthoma 



NEOPLASM ATA-NEW GROWTHS. 
Crusted papules. 
y Degeneration. 



Lupus vulgaris 

" erythematosus 
Scrofuloderma 
Tuberculosis 

" verrucosa cutis 

Syphiloderma 

a. erythematosutn 

b. papulosum 

c. pustulosum 

d. tuberculosum 

e. gummatosum 



Infiltrating. 



CLASSIFICA TION. 



55 



Lepra 

a. ana?sthetica 

b. maculosa 

c. tuberosa 
Kliinoscleroma 
Leucoplakia 

Keloid 

Fibroma 

Acrochordon 

Myoma 

Neuroma 

Nsevus vasculosus 

Telangiectasis 

Angioma serpiginosum 

Angiokeratoma 

Rosacea 

Lymphangioma 

Dermatolvsis 



• Infiltrating. 



■ Benign. 



Carcinoma 

Paget's disease 

Epithelioma 

Sarcoma 

Mycosis fungoi'des 

Yaws 

Verruga Peruana 

Furnnculus orientalis 

Phagedena tropica 



Malignant. 



Class VII. NEUROSES -SENSORY DISEASES. 



Hyperesthesia. 
Dermatalgia. 
Pruritus. 
Anaesthesia. 



Class VIII. 



MORRI APPENDICIUM- 
APPENDAGES. 



-DISEASES OF THE 



A. Sweat Glands. 

Hyperidrosis. 

Bromidrosis 

Chromidrosis 

Hsematidrosis 

Uridrosis 

Anidrosis. 

Miliaria crystallina (sudamina) 

Miliaria papulosa. 

Hydrocystoma. 



Most prominent primary lesion. 
Excessive secretion. 

Altered quality. 

Deficient secretion. 
Vesicles. 
Inflammation. 
Vesicles. 



56 



G ENERA L CONSIDER A TIONS. 



B. Sebaceous Glands. 
Seborrhcea. 

«. oleosa. 
b. sicca. 
Milium. 
Comedones. 
Acne vulgaris. 

" indurata. 

" varioliformis. 
Sebaceous cyst. 
Adenoma sebaceum. 
Asteatosis. 

C. Hair. 
Hypertrichosis. 
Atrophia. 
Alopecia. 

" areata. 
Keratosis pilaris. 
( Ymcretions. 
Trichorrhexis nodosa. 
Canities. 
Sycosis. 

Folliculitis decalvans. 
Dermatitis papillaris capillitii. 
Nsevus pilosus. 

Plica Polonica. 

Trichiasis. 

Distichiasis. 

D. Nails. 
Pterygium. 
< )nychia. 
Paronychia. 
Atrophia. 

( >nychogryphosis. 
Leucopathia unguium. 



Most prominent primary lesion. 
Excessive secretion. 



Retained secretion. 
Inflammation. 



Retained secretion. 
Papules. 

Deficient secretion. 

Excessive growl h. 
Defective growth. 
Baldness. 

" in patches. 
Retention. 

Growths on the hair shaft. 
Nodes on hair shaft. 
Loss of pigment. 
Inflammation. 

Alopecia with inflammation. 
Inflammation. 

Excessive growth with pigmenta- 
tion. 
Felting. 
Misplacement of cilia. 

Overlapping of nail fold. 
Inflammation. 

Defective growth. 

Overgrowth. 

White spots in nails. 



Class IX. PARASITI— PARASITES. 
A. Vegetable. 

Favus. Parasite — Achorion. 

Trichophytosis. " —Trichophyton. 

a. barfce. 

6. capitis. 

c. corporis. 

d. cruris. 

e. unguium. 
Cliromophytosis (tinea versicolor). Parasite — Microsporon. 



Erythrasma. 

Mycetoma. 

Actinomvcosis. 

Pinta. 



■Mi 



tcrosporon 



mum. 
Tumors. 



Discolored macules. 



SOME DEBMATOLOGICAL DONT'S. 57 

B. Animal. 

Scabies. Parasite — Acarus. 

Pediculosis. " — Pediculus. 

a. capitis. 

b. corporis. 

c. pubis. 

Cysticercus cellulosse 'cutis. Parasite — Toznia solium. 
Dracontiasis. .■ " — Filaria medinensis. 



Some Dermatological Dont's. 

Don't make your diagnosis from the history of a case, 
because if you do you will often be led astray. Make it 
from the eruption that you see, and then substantiate or 
destroy this by the history of the case, if you will. 

Don't fail to think of the possibility of every case being 
either syphilis or eczema ; and 

Don't fail to master these two diseases as thoroughly as 
possible, because if you learn to recognize these two you 
will have gone a long way in diagnosis. If they can be 
excluded, then the field of possible " might be's " is con- 
siderably narrowed. 

Don't make the diagnosis of syphilis on account of a 
syphilitic history, because you can often get a history of 
syphilis in a non-syphilitic case. 

Don't expect much, if any, history of syphilis in a 
woman, because you very frequently will not get it. In 
women the early symptoms of the disease are often so 
slight that they are not observed by them. 

Don't throw out the diagnosis of syphilis on account of 
an eruption itching, because some syphilides, especially the 
papular variety, do itch at times. The not itching of an 
eruption is better presumptive evidence of syphilis than is 
itching positive evidence against it. 

Don't make the diagnosis of lichen planus from the 
presence of flat angular papules with depressed centers 
alone, because identical lesions will at times be met with 
in eczema, syphilis, and psoriasis. 

Don't depend upon getting the bleeding-points springing 
out of the delicate pellicle after carefully scraping off the 
scales, for your diagnosis of psoriasis, because you can 
produce the same thing in other diseases. In fact, 



58 GENERAL CONSIDERATIONS. 

Don't depend upon any one symptom, but make your 
diagnosis from the general make-up of the disease as a 
whole. 

Don't forget that many diseases of the skin are depend- 
ent upon disturbances in the general health of the patient. 
Therefore, 

Don't fail to inquire into the performance of the func- 
tions of the various organs of the patient, and to put him 
into as good a physical condition as possible. 

Don't tell your patient that it is dangerous to cure his 
skin disease rapidly, because it is not. If you 

Don't know how to treat the case, ask advice of someone 
who does. 

Don't encourage the popular notion that there is danger 
of an eruption striking in, because it never does. 

Don't give arsenic for every skin disease, and, es- 
pecially, 

Don't give it in acute eruptions. Its sphere is in the 
chronic scaly eruptions, such as chronic psoriasis. 

Don't forget that most cases of pruritus are due to in- 
ternal causes ; and that in them external treatment is 
wasted ; and 

Don't forget the bedbug and the pediculus as possible 
causes of the trouble. 

Don't forget that the greatest secret in the treatment of 
eczema, and many other skin diseases, is not what par- 
ticular drug or formula is " good for " the disease, but a 
knowledge of the great principle that acute diseases need 
soothing remedies and subacute and chronic diseases need 
stimulation. 

Don't expect to cure an inveterate eczema with thick- 
ened skin by means of a soothing ointment, such as that of 
the oxide of zinc, because you will only waste your time 
and the patient's money. 

Don't use tar in an acute eczema, because it is a stimu- 
lant, and what we want at this time is to soothe the in- 
flamed skin. It is appropriate in a subacute or chronic 
ease. 

Don't allow water to touch the skin in acute eczema, 
because it always irritates in such a ease. 



SOME DERMATOLOGICAL DONT'S. 59 

Don't use a thick ointment on the hairy scalp, because 
it makes a disagreeable mess of the hair, and will not be 
" popular" with your patient. Even lard is not a pleasant 
vehicle for such applications. Vaseline and the oils are 
more elegant excipients. 

Don't order the hair to be cut from the head of a young 
or old woman in any disease of the scalp, because, except 
in the case of a peculiarly stupid or careless patient, it is 
never necessary, and it is always disagreeable to the 
woman. 

Don't allow a patient with ringworm to go to school, 
because if you do you will be responsible for the spread of 
the disease. 

Don't pronounce a ringworm case well and incapable 
of spreading the contagion until you are sure that it is 
well ; and 

Don't be sure about it until there are no more " stumps " 
on the scalp, and you can find no more of the fungus in 
the hair. 

Don't use the name " barber's itch " for anything but 
trichophytosis barbae, because it is well not to use terms 
loosely to cover several different diseases. 

Don't use chrysarobin on the face or scalp, because it is 
very apt to cause a good deal of dermatitis with oedema 
and to stain the skin a deep mahogany-red. 

Don't forget to caution a patient to whom you have 
given chrysarobin not to touch his face with his hands 
after applying the drug, because if you do you will have 
either a mad or a frightened patient in your office. 

Don't pronounce a patient addicted to the excessive use 
of alcoholic beverages on account of his having rosacea, 
because there are lots of other things besides alcohol that 
will cause it. 

Don't use the positive pole of the battery for the needle 
in destroying hair by electrolysis, because if you do you 
will leave more or less permanent marks in the skin. 

Don't apply a sulphur preparation after using a mer- 
curial upon the face, or vice versa, because if you do you 
will raise a fine crop of comedones. 

Don't use a camel's hair brush for making applications 



60 GENERAL CONSWERA TIONS. 

of corrosive sublimate, because if you do some of the salt 
will be left on the brush each time it is used, and you 
will soon have a stronger solution than you bargained for. 
Always use a little cotton on a wooden toothpick or a 
splinter of wood. 

Don't allow a fine-toothed comb to be used on the scalp, 
because it scratches and irritates the scalp. 

Don't encourage or advise the use of pomades on the 
healthy scalp, because they are prone to become rancid 
and inflame the scalp. They are also unnecessary if the 
hygiene of the scalp is properly looked after. 

Don't forget that dandruff is the most frequent cause 
of premature baldness, because if you remember this you 
may be able to prevent the fall of some one's hair for 
some time. Therefore, 

Don't fail to treat everv case of dandruff. — The Medical 
Record, December 29, 1888. 



PAET II. 

THE DISEASES OF THE SKIN AND THEIR 
TREATMENT. 



Abscess. 

Symptoms. Abscesses are very frequently met with as 
complications of diseases of the skin, such as acne, eczema, 
scabies, pediculosis, and other acute dermatitides. As 
thus met with they are usually of small size, though at 
times, as upon the scalp of a strumous child, they may 
attain considerable dimensions. They form rounded swell- 
ings that are at first tense but soon become soft and fluc- 
tuating. When incised more or less thick pus escapes. 
Their most frequent locations are : upon the scalp with 
eczema ; upon the face and back with acne ; about the 
neck arising from broken-down glands ; and upon the ex- 
tremities with scabies and pediculosis. Apart from a slight 
amount of discomfort, they do not give rise to subjective 
symptoms as a rule, and are, indeed, trivial affections. Of 
course, this does not apply to abscesses as seen by the 
surgeon. They may open of themselves and discharge 
their contents upon the skin. More commonly they are 
very sluggish in their course, and must be evacuated by 
some surgical procedure. 

Diagnosis. An abscess differs from a furuncle by not 
being raised into a conical mass ; not having a central 
core, and by being less firm to the touch. It differs from 
a carbuncle by an entire absence of marked constitutional 
disturbance, brawny infiltration, intense inflammation, and 
cribriform mode of opening. Kerion often resembles an 
abscess, but differs from it in its uneven surface and its 
firmness to the touch. Syphilitic gummata are sometimes 
mistaken for abscesses and opened. They may be recog- 
nized by their dark-red color, the absence of pain and 



62 DISEASES OF THE SKIN. 

discomfort, and the history of their growth. They grow 
slowly, beginning below the skin. There is generally 
more than one present, and then they are grouped. The 
aspiration of .the tumor will decide the question. From 
an abscess we obtain pus; from a gumma a little bloody 
fluid. 

Treatment. The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, and 
the part dressed with carbolized vaseline if small, or anti- 
septically if larger. It is sometimes necessary to swab out 
the cavity with a solution of carbolic acid of 2 drachms to 
the ounce, to destroy the abscess wall and prevent the re- 
formation of the abscess. 

Acantholysis. A disease characterized by loosening or 
separation of the mucous layer of the epidermis. See 

Epidermolysis. 

Acanthosis Nigricans. Under this name cases have 
been reported by Pollitzer, Janovsky, Crocker, and a few 
others. It occurs at any time of life, but most often 
between the thirtieth and fortieth year. It consists in a 
dirty-brown to bluish-gray or black discoloration of the 
skin and mucous membranes, with more or less papillary 
outgrowths and seborrhoeal warts. On the places that are 
most discolored the papillary outgrowths are most marked. 
The skin is thickened to a greater or less degree, and is 
not scaly. The regions affected are the face, neck, mucous 
membranes of the mouth (especially the tongue), the backs 
of the hands (especially the fingers), the axillae, groins, 
genito-anal regions, and abdomen. Women are more often 
affected than men. Late in the disease the hair and nails 
are lost. The cause of the disease is unknown. Rille 1 
regards it as a form of keratosis. Darier, J. Burmeister, 2 
and others say that it is often due to cancer of the abdom- 
inal sympathetic. The prognosis is bad, death resulting 
in from eight months to two years. In some cases the 

1 Wien. med. Wochenschr., 1S97, xlvii., 1019. 

2 Arch. f. Dermat. u. Syph., 1899, xlvii., 343. 



A ONE. 63 

duration is much longer. Treatment thus far has been 
unavailing. 

Acne. Synonyms : Varus, Ionthus ; (Ger.) Finnen ; 
(Fr.) Acn6, Bouton ; Stone-pock, Whelk, Pimple. 

Acne is an inflammatory disease of the sebaceous glands 
and the hair follicles, characterized by an eruption of 
papules, pustules, or tubercles upon the face, neck, shoul- 
ders, or chest, which usually begins at puberty and tends 
to run a chronic course. 

Different writers and teachers have applied different 
names to the various phases of acne. They had best be 
forgotten, except in so far as they are of historical value. 
The term acne is applied by the French school to all dis- 
eases of the sebaceous glands. It would seem to be the 
wiser plan to reserve the name for the disease as just de- 
fined. Regarded thus, we have but two varieties of acne, 
namely, acne vulgaris and acne indurata. 

Acne Vulgaris, or Simplex, is either papular or pustu- 
lar in character, though usually it is a combination of the 
two, together with more or less comedones and a certain 
amount of seborrhoea. 

Symptoms. If only papules exist (A. papulosa), the 
face, shoulders, or chest will be found to be dotted more or 
less profusely with pinhead-sized, acuminated elevations of 
the skin, of a pinkish to red color, and with a central open- 
ing at the summit. Very often the central openings will 
be filled with blackish specks. The lesions are then spoken 
of as A. punctata. This term is used by some writers to 
designate the comedo, but improperly according to our 
definition. It is rare that acne exists only in the papular 
form. More usually it will be found that here and there 
the papules are surmounted by a pustule, or a pustule has 
taken the place of a papule. We now have A. pustulosa. 
In strumous subjects the pustular element preponderates 
over the papular, and the face may be greatly disfigured 
by the large number of lesions present upon it. The pus- 
tules are from pinhead to small-pea size and have an in- 
flamed base. (Fig. 5.) 

Together with the acne and the comedones we meet with 



64 



DISEASES OF THE SKIS. 



milia quite commonly, and the affected parts are usually 
greasy to the feel, showing that the sebaceous glands sym- 
pathize in the disease. AVe now have a fair picture of a 
typical case of acne vulgaris. The face, back, neck, or 
chest, or all four, are dotted over in an irregular mannei 
with blackish points, papules, and small pustules; the skin 

Fig. 5. 




Acne vulgaris. 
(From Prof. George H. Fox's Service in the Vanderbilt Clinic.) 

of the nose and forehead looks shiny and feels greasy, and 
perhaps there are some milia scattered about the region of 
the eyes. At times the eyes will appear inflamed and hyper- 
aemic, especially in young, otherwise robust subjects. More 
commonly the complexion will have that pasty appearance 
indicative of what has from old times been called the 
strumous condition. If the inflammatory process has been 
unusually severe, we may find a considerable amount of 



ACNE. 65 

scarring. Usually acne vulgaris does not leave permanent 
scars. The profuseness of the eruption varies greatly. In 
some cases there will be but a few lesions, while in other 
cases they will be present in vast amount. This form of 
acne generally occurs in young people. The duration of 
the individual lesion is short, as it soon either dries up or 
discharges its contents. If the papules are squeezed, little 
plugs of sebaceous matter will be expressed. If the 
papulo-pustules are treated in the same way, there will 
first be pressed out a small sebaceous plug and then a drop 
or two of pus. 

Acne Indurata is a pustular acne in which the pustules 
are of large size and seated upon deeply infiltrated bases. 
They are most commonly sparsely dispersed, and take 
the form of purplish " lumps " of pea to bean size which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch than by sight, being located deeply 
in the skin. Sometimes they take the form of cutaneous 
abscesses, and if by chance several are located close to one 
another they may run together and form a raised, dark- 
red, doughy mass. When incised, these lesions sometimes 
give exit to a large amount of thick pus. They usually 
leave scars, which sometimes are very disfiguring unless 
they are opened very early in their course. It maybe the 
only form of acne present, or it may be combined with 
acne vulgaris. This form of acne usually occurs at a more 
advanced age than does acne vulgaris, though it is not in- 
frequently met with in early life. While occurring on the 
face, the neck and back are the regions in which it is prone 
to develop in the most marked manner. (Fig. 6.) 

Etiology. Acne is one of the most common of skin 
diseases, and its great predisposing cause is youth. The 
disease first shows itself about the time of puberty and 
manifests a tendency to disappear when the body is fully 
developed — that is, from the twenty-third to the thirtieth 
year, though it may continue much later. A few rare 
cases have been reported of acne at an early age. Thus, 
Chambard l met with a case in a girl of six and a half 
1 Ann. de derm, et de syph., 1878-79, x., 259. 
5 



66 DISEASES OF THE SKIN. 

years. The indurated form of acne appears later than the 
simple form, usually after the twenty-fifth year. Both 
sexes are affected, but the disease is more frequent in fe- 
males than in males, and in them begins at an earlier age. 
The period of youth is the time of great developmental ac- 
tivity in which the sebaceous glands take part, and it is 
probable that there is a too great activity of the glands and 
an improperly formed sebum is the result. Normally, the 

Fig. 6. 




Acne indurata of the back. 

product of the fat-glands is an oily fat. In acne an in- 
spissation of the fat takes place, forming a plug that acts 
as a foreign body and sets up an inflammation. 

Individuals with thick, pasty, pale skins with patulous 
follicular mouths are predisposed to acne. These pecu- 
liarities of skin are met with in scrofulous subjects. The 
patulous follicular mouths give ready lodgement to foreign 
matters, and comedones are thus formed. This prevents 
the escape of the follicular contents, a plug is formed, and 



ACNE. 67 

we have an acne papule or pustule. Comedones are, there- 
fore, an exciting cause of acne. 

Heredity has been asserted by some to be a predisposing 
cause of acne, but the disease is so common that there is 
no certainty about this factor. 

Digestive disturbances, while not causing acne, are most 
active in aggravating it. These may take the form of 
dyspepsia, stomachal or intestinal ; or mal-assimilation ; 
or failure on the part of the liver or pancreas to perform 
its physiological functions ; or sluggishness of the large 
intestine and consequent constipation. Improper diet, so 
common in early life, is responsible for the maintenance of 
many cases of acne. 

Next to disorders of the digestive organs, those of the 
sexual organs are supposed to have most influence in 
aggravating acne. But, inasmuch as most cases of acne 
are amenable to the influence of diet and regulation of 
digestive disorders without any attention being given to 
sexual disorders, it is probable that the latter are impor- 
tant etiological factors in comparatively few cases. Indeed, 
it is not improbable that the acne that appears on the faces 
of women at each menstrual period, and at that time alone, 
as well as the aggravation of an already existing acne, is 
due to the more or less pronounced disturbance of the 
digestive organs so frequently observed at the same time. 
In some cases acne does seem to be a reflex irritation 
from the uterus. Amenorrhoea is the uterine derangement 
most frequently encountered, but that condition is but one 
evidence of a general constitutional disorder rather than 
a disease in itself. 

Masturbation and continence have each been blamed as 
excitants of acne. The former of these of itself does not 
cause acne, but its well-known effects on the nervous, 
moral, and physical condition of growing youths would 
sufficiently account for any part it may have in producing 
acne. There is absolutely no proof that continence causes 
acne. If a boy or young man keeps himself in a constant 
state of unrest by lascivious thoughts, that is not true con- 
tinence, even though he does not masturbate nor copulate. 
It is safer for us to say that bad sexual hygiene may cause 



68 DISEASES OF THE SKIN. 

acne, rather than to ascribe it either to masturbation on 
the one hand or to continence on the other. 

It may be stated as a broad, general rule, that anything 
that lowers the general health of the patient contributes 
to the production of acne. We have space to enumerate 
only some of these exciting causes. Thus, we have the 
vague state " general debility," anaemia and chlorosis, ox- 
aluria and uraemia, rheumatism and gout, poor circulation, 
mental and physical exhaustion, and chronic malaria. J. 
Sclmtz l believes that deficient heart action and consequent 
slowness of the circulation are the underlying causes of 
acne, as they lead to an alteration of the sebaceous secre- 
tion. 

In 1881 Denslow 2 advanced a theory that a want of 
tone in the arrectores pilorum muscles, either alone or 
together with an over-production of sebaceous matter and 
its retention in the sebaceous glands, was an important 
etiological factor in acne. As the muscles failed to act 
with sufficient vigor, they did not perform one of their 
offices — the emptying of the follicles — and this allowed 
of the retention of glandular products and consequent 
acne. 

Acne of the pustular variety is said to be due to the 
entrance of the staphylococcus aureus et albus into the fol- 
licles, which offer proper ground for their growth. Unna 
believes that there are several forms of micro-organisms 
found in the comedones, and that one, a small bacillus, is 
the cause of the disease. He regards the usually accepted 
systemic causes of acne as only aggravants of the disease, 
and teaches that the disease is a purely local one. His 
views have been largely accepted. T. C. Gilchrist 3 has 
demonstrated a special bacillus in pustular acne that he 
regards as the cause of the pustules. For it he proposes 
the name bacillus acnes. He wisely insists that a certain 
kind of skin is necessary for its growth and the production 
of its effects. 

Pathology. Acne may begin in the hair follicles or 

1 Arch. f. Dermat. a. Svph., 1900, li., 323. 

2 New York Med. Jour'n., 1881, xxxiii., 189. 
8 Trans. Amer. Dermat. Assoc, 1899, p. 97. 



ACNE. 69 

in the sebaceous glands, and may be due either to their 
becoming clogged up by inspissated sebum and acting like 
a thorn in the flesh, or to their invasion by micro-organ- 
isms, either from without or within, which set up a sup- 
purative perifolliculitis. The papules of acne are located 
in the upper part of the skin, while the pustules are 
deeper. In very bad cases the follicle may be entirely 
destroyed by the perifolliculitis and scars will be left. 
The sebaceous glands do not take a very active part in the 
process. Micro-organisms are found abundantly in the 
suppurating gland cavities. 

In acne indurata we find the hair follicles enormously 
dilated, their orifices filled with corneous cells, and their 
cavities almost converted into cysts. The connective tissue 
about the follicles shows decided signs of inflammation 
and may be increased in amount. Very often the follicles 
are destroyed by the perifollicular inflammation. When 
the perifolliculitis is severe and extensive the deep layers 
of the skin become involved, and we have abscess forma- 
tion. 

Diagnosis. Acne is to be differentiated from rosacea, 
papular and pustular eczema, sycosis, the small pustular 
and tubercular syphiloderm, and variola. 

Rosacea is due to a dilatation of the blood vessels, and 
is attended by hyperemia and telangiectases. If there are 
any pustules, they are superficial, and if excised give exit 
to only a drop of pus. Acne is a disease of the sebaceous 
glands, and papules and pustules constitute the disease. 
They are often large, and if excised will give exit to a 
plug of sebaceous matter and thick pus. Rosacea, as a 
rule, occupies the middle third of the face alone, the fore- 
head, nose, and chin. Acne is scattered over the whole 
face, and is often found on the shoulders. 

Papular eczema may occur at any age ; acne usually oc- 
curs between the ages of fifteen and twenty-five. Papular 
eczema rarely is seen on the face alone, and is prone to 
attack the trunk and extremities ; acne often occurs on the 
face alone, and is never disseminated over the limbs and 
trunk. In eczema there is an absence of comedones ; the 
papules are often surmounted by or change into vesicles ; 



70 DISEASES OF THE SKIN. 

they tend to form patches, and the disease is very itchy, so 
that scratch-marks are almost invariably found. "When it 
gets well it leaves no trace on the skin. These symptoms 
are foreign to acne. 

In pustular eczema, or what has been called impetigo 
simplex, we have a large number of small pustules run- 
ning together to form patches which rapidly become cov- 
ered with greenish or yellow crusts. The disease runs a 
far more acute and stormy course than does acne, and is 
itchy. It is very frequently met with in children, whom 
acne rarely affects. 

Sycosis is a pustular disease affecting the hair follicles 
alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudimentary 
hairs. 

The small pustular sypkiloderm, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain 
other evidences of syphilis, such as the remains of the 
initial lesion, enlarged lymphatic glands, mucous patches, 
or the like. It is usually more uniform in its lesions, 
and these are plainly papulo-pustular. The color of the 
areola is more that of raw ham and less inflammatory 
looking than is that of acne. The lesions sometimes show 
a tendency to group into segments of circles, and each 
lesion undergoes a definite development. They sometimes 
leave small, smooth, white scars that may disappear in a 
few months. The tubercular syphiloderm could be mis- 
taken for an indurated acne. In it there will usually be 
found other evidences of syphilis. The lesions group 
themselves into patches that are kidney-shaped or form 
segments of circles. The tubercles are dark-red or raw- 
ham colored, surrounded by a well-marked areola, firm to 
the touch, and do not contain pus. They may ulcerate, 
or, being absorbed, leave pigmented and punched-out 
cicatrices, and, finally, smooth white scars. The scars left 
by acne indurata are puckered and more disfiguring. 

Variola could scarcely give rise to much doubt, as it 
has well-marked constitutional symptoms, and its lesions 
undergo a definite and characteristic development. 



ACNE. 71 

Treatment. In the treatment of acne we can obtain 
a cure most surely by attention to the general condition of 
the patient ; most rapidly by a combination of internal and 
local treatment. 

We, therefore, begin the treatment of a case by a careful 
inquiry into the general condition of the patient, and 
endeavor to regulate any, even the slightest, derangement 
of the internal organs. By so doing we may find no one 
of those conditions enumerated under the etiology of the 
affection, and the patient may consider himself as in the 
best condition. Further observation will probably reveal 
some deviation, though slight, from perfect health. The 
relief of constitutional disorders is conducted according to 
the principles of general medicine, and cannot be given 
here. Many of the cases require cod-liver oil and iron as 
general measures quite apart from any evident disease. 
This is seen in the sluggish cases occurring in strumous 
subjects with pasty skins. In plethoric subjects with a 
good deal of inflammation attending the acne laxative 
agents, such as a tenth of a grain of calomel in tablet tritu- 
rates, given three or four times a day,, will aid in a cure, 
quite aside from any constipation. 

Diet and hygiene are agents to be employed rather 
than drugs. It is impossible for us to lay down fixed 
principles of diet, and it is better to study each case by 
itself. The well-to-do are all prone to eat too much, and 
it is remarkable how rapidly their acne will improve by 
reducing their diet to the simplest elements. In many of 
them a milk diet for a few days, provided milk agrees 
with them, will accomplish a marked benefit. It must be 
remembered that milk is a food, and that when other foods 
are partaken of freely the taking of milk at the same time 
may overload the stomach. The cutting of milk from the 
dietary will be of great benefit in some cases of acne. It 
is a good rule to cut off from the dietary all pastry, cakes, 
candy, sweets, hot breads, pancakes, greasy soups, articles 
fried in fat, rich gravies — in fact, all those things that are 
most apt to tempt the palate. Oatmeal is often cited as 
a cause of acne, and had best be dropped. Hot water 
before meals, a glass of water at meals and two hours 



72 DISEASES OF THE SKIN. 

after meals, are good directions for the use of things 
to drink. Tea, coffee, malt liquors, sweet and heavy 
wines are to be avoided. Butter may be used freely, 
and care must be had not to restrict the diet too greatly. 
Many young girls almost starve themselves in the 
mistaken idea that a low diet will give them a fine com- 
plexion. 

Exercise must be insisted on, an hour or more a day 
being spent in walking, horseback or bicycle riding, row- 
ing, or other out-dour exercise. Daily bathing or dry 
rubbing will keep the skin in healthy condition, and 
Turkish baths are often beneficial. Where patients either 
can not or will not take a daily bath much good will be 
accomplished by having them bathe the chest and back 
daily with cold water and then dry the skin by brisk rub- 
bing with a coarse towel. 

Arsenic, sulphide of calcium, glycerin, and ergot are the 
drugs that are given by the mouth as curative in acne. 
Arsenic is the oldest and most honored of these. It is of 
use only in very chronic, sluggish cases, and the more pap- 
ular the case the more useful the arsenic. It should be used 
as the last resort, not as the first. Fowler's solution is the 
most frequently used preparation, in doses of from three 
drops three times a day, as an initial dose, gradually increased 
to fifteen or twenty drops or until the appearance of some 
symptoms of poisoning. Piffard l recommends bromide of 
arsenic in the dose of y^ to -^ grain two or three times a 
day in rather acute cases of acne. A convenient method of 
administration is to make a one per cent, solution in alcohol, 
and give one or two minims of that in a wineglassful of 
water. Should it cause gastric irritation the dose must be 
lessened. I have used this in a number of cases with good 
results. The sulphide of calcium has its advocates for slug- 
gish pustular eases. It should be given in small doses, 
from T y (r to y 1 ^ grain, in gelatin-coated pills or fresh tablet 
triturates. One pill may be given four or five times a day 
until the tendency to pustulation is increased. It then 
should be discontinued until the exacerbation has subsided, 
when it should be again administered. It is of doubtful 
1 Journ. L'utan. and Yen. Dis., 1884, ii., 71. 



ACNE. 73 

value. Glycerin was advocated by Gubler 1 as a cure for 
acne, and is well spoken of by others. It must be given 
in doses of a teaspoonful three times a day increased to a 
tablespoonful, and is of most use in strumous cases. Ergot, 
either the fluid extract in doses of half a drachm three 
times a day or a corresponding amount of ergotin, has 
many advocates. 

Chrysarobin, internally, has been recommended by Stoc- 
quart, 2 in the dose of one-sixth to one-half grain. Small 
doses of the bichloride of mercury are sometimes curative 
where there is much infiltration. 

Iodide of potassium in doses of from one to five drops 
of a saturated solution, well diluted, taken three times a 
day before meals, sometimes is useful in pustular acne. 

Sherwell 3 advocates the passage of the cold sound through 
the urethra of a young man suffering with acne. Hot 
vaginal douches are recommended by some in acne of 
women. 

The objects of local treatment are to open up the pus- 
tules and papules and allow of the escape of their con- 
tents, to stimulate the skin to a more healthful action, 
and, according to the bacteriologists, to prevent further 
infection of the follicles by micro-organisms. To attain 
the first two objects we may employ either a quick or a 
slow method ; to attain the last object we employ an anti- 
parasitic. The best preventive local treatment is to keep 
the skin clean and its nutrition good by the use of soap 
and water. I have found great benefit from the use of a 
soap proposed by Unna, whose base is liquid paraffin, 30 
parts, and dried-out pure soap, 70 parts, to which is added 
superoxide of soda, from 3 to 10 per cent. 

An efficient local treatment for nearly all cases of acne 
is to put the skin somewhat on the stretch and scrape it 
somewhat roughly with a large and long, blunt dermal 
curette with a fenestrated blade (Fig. 7). This tears off all 
the tops of the lesions, presses out all the contents of the 
follicles, and stimulates the skin in a most vigorous manner. 

1 Journ. de Bruxelles, 1870. 

2 Ann. de derm, et de syph., 1884, v., 15. 

3 Journ. Cutan. and Ven. Dis., 1884, ii., 335. 



74 



DISEASES OE THE SKIN. 



It is followed by some bleeding, which it is well to encour- 
age by the use of warm water. " Deep pustules or cutaneous 
abscesses, if not emptied by the curetting, should be incised. 
All comedones should be squeezed out. The after-treatment 



Fox's ring curette. 

consists in washing the face with warm water and soap and 
dusting with cornstarch, to which may be added oxide of 
zinc. Instead of this a solution of peroxide of hydrogen 
may be dabbed on. The scraping is to be repeated two or 
three times a week. The procedure seems rough, but after 
the first scrapingthe patients do not mind it much, and the 
result is the attainment of a smooth skin in a compara- 
tively short time. With this plan we may use a sulphur 
ointment, a drachm to the ounce, to be applied twenty-four 
hours after the scraping, or a wash of bfcfyroride of mercury, 
half a grain to the ounce of dilute ale^fol, to which may 
be added a little glycerin. Thus will we fulfil all three 
of the indications for treatment. 

The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. S) and 
squeezing out every comedo. This is to be done once or 
twice a week and a sulphur preparation used between 
times. Very timid patients who will allow no surgical 
interference may be treated according to the same princi- 
ples by directing them to scrub their faces thoroughly 

Fig. 8. 



Fox's aene lance and dermal curette. 



once a day with green soap, or tincture of green soap, and 
leave the lather on. After a day or two of good scrubbing 
an amount of dermatitis will be excited sufficient to cause 
the old skin to peel off, while the tops of many of the 
lesions will have been torn off and the skin will have been 



ACNE. 75 

decidedly stimulated. Not until the skin has become 
scaly and feels tense to the patient should a soothing oint- 
ment be applied. Repeated applications of the soap fric- 
tions will slowly bring about improvement. Rubbing the 
face with fine sand or coarse cornmeal will do good, but 
is not so elegant. 

Massage to the skin will give nearly if not quite as 
good results as the rougher curettage. The tips of the 
fingers should be dipped in cold cream, and then, pressure 
being exerted by them, the skin of the forehead should be 
deeply stroked from the middle line out and over the 
temples. The nose should be stroked from the bridge out- 
ward and downward. The skin of the cheeks should be 
pinched up and rolled between the fingers and thumb. 
These movements facilitate the emptying of the follicles. 
The application of the galvanic current by means of the 
roller electrode, or by ordinary sponge electrodes, will in 
some sluggish cases prove helpful. G. W. Wende 1 recom- 
mends placing the electrodes in close proximity on the 
face and constantly changing their position until the skin 
becomes reddened. The amount of current to be used 
depends upon the ability of the patient to bear pain. 
Where the skin is very sensitive the anode can be held 
in one place and the face gently stroked with the cathode, 
using five to ten cells for fifteen minutes. 

A vast number of prescriptions have been written which 
are "good for acne," the majority of which contain sulphur 
in some form, and in the strength of half a drachm to one 
drachm to the ounce, and in ointment or lotion form. 
Sulphur in powder form is good if the patient doesn't 
mind the odor. The ordinary sulphur ointment of the 
Pharmacopoeia is as good a preparation as any. It may 
be made more elegant by adding some perfume. The sul- 
phuret of potassium may be used in the following : 



R Potass, sul phuret.. 
Zinci sulpnat 



3j ; aa 3 5 



Aquae rosse, §iv ; 100 M. 

This preparation is commonly spoken of as " Lotio alba," 
1 Buffalo Med. Journ., 1898-99, xxxviii., 254. 



76 DISEASES OF THE SKIN. 

and is one of the most useful of the compounds of sulphur. 
It is to be applied every day after being well shaken. 

Vleminckx's solution is an active preparation in causing 
the old skin to exfoliate. It is composed of — 

R Calcis, Sss; 15 

Sulph. sublim., ^j ; 30 

Aquae destil., £x ; 300 

Cook to gvj (192.) and filter. 

After this has been left on a few hours it should be washed 
off and a soothing ointment, such as ungt. zinci oxid. or 
ungt. aquae rosae, applied. It is most useful in acne of the 
back. 

The best sulphur ointment, according to my experience, 
is one proposed by Unna, as follows : 



R Adepis lanse, vS'jss > 10 

Ac. acetici dil., ^ij gr. xlv ; 11 

Adepis benzoat., 3ijss ; 10 

Sulph. praecipitat., gr. xlv ; 3 



M. 



This is to be applied at night, and, when practicable, in the 
morning. 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It should be borne 
in mind that a mercurial must never be applied to the skin 
until all traces of sulphur are removed, or vice versa, be- 
cause if the precaution is forgotten the black sulphide of 
mercury will be formed, which will give the skin the ap- 
pearance of being sown with powder grains. A lotion of 
corrosive sublimate, 1 : 2000 to 1 : 1000, may be mopped on 
once or twice a day, or an ointment of the protiodide, as 
recommended by Duhring, may be used : 

R Hydrarg. protiodid., gr. v-xv ; 1 

Hydrarg. amnion., gr. x-xxx ; 2 

Ungt. simplicis, 3J ; 30 M. 

Lassar l recommends the following paste : 

R /3-naphtol, 10 parts. 

Sulph. pnecip., 50 " 

Vaseline, ) -- OK « ,, 

Sapoviridis, } aa 25 M " 



Therap. Monatshefte, 1887, No. 1. 



ACNE. 77 

This is to be spread upon the skin to the thickness of the 
back of a knife-blade, and left on for fifteen or twenty 
minutes. It is then to be wiped off with a soft cloth, and 
the skin powdered with talc. The skin becomes inflamed, 
turns brown, and peels off. The application is to be re- 
peated every day until the skin does peel off. Desquama- 
tion can be hastened by the application of Lassar's paste 
with two per cent, of salicylic acid. 

Resorcin has been commended, used in twenty per cent, 
strength. Ichthyol, the ammonio-sulphate, is recom- 
mended by Unna for acne, either as a three to five per cent, 
ointment or as a three to ten percent, aqueous solution. As 
much as fifteen grains of it are to be taken by the mouth 
during the day. A mild corrosive sublimate wash is to 
be applied to the face until the patient goes to bed, and 
then a ten per cent, aqueous solution, or paste of ichthyol, 
is to be kept on till morning. Startin l has employed 
local steam baths by means of a steam atomizer, with suc- 
cess. The steaming should be kept up for twenty or 
thirty minutes, and tincture of benzoin used in the 
medicine cup. While useful in some cases it does harm 
in other cases. 

The foregoing remedies are all specially adapted to more 
or less sluggish cases, the type met with in the great ma- 
jority of instances. In very recent and quite inflammatory 
cases, besides the administration of laxatives and the regu- 
lation of the diet, the patient should be directed to bathe 
the face with hot water, either with or without the addi- 
tion of borax (sij to Oj), and apply a soothing ointment. 
When the inflammatory symptoms subside recourse must 
be had to some of the above detailed methods of treat- 
ment. 

Bathing of the face with hot water before the appli- 
cation of any lotion or ointment should be advised. In 
indurated acne, where cutaneous abscesses have formed 
and the lesions are discrete, each abscess will have to be 
opened up with a lancet, the contents of the abscess dis- 
charged, and carbolic acid, either pure or diluted, intro- 
duced, by means of a little cotton around the end of a bit 

1 Lancet, 1889, L, 934. 



78 DISEASES OF THE SKIN. 

of wood, into the abscess cavity, so as to destroy the lining 
membrane. 

Individual acne lesions can sometimes be aborted by 
touching them with pure carbolic acid or acid nitrate of 
mercury. 

Prognosis. By persistent effort and careful regulation 
of all the bodily functions a great improvement can be 
effected, one fairly deserving the name of cure. But it is 
often hard to prevent the occasional appearance of a few 
acne lesions until the period of life in which acne usually 
occurs is passed. There are some cases in which we can 
do but little, because we are unable to remove the under- 
lying cause. 

Acne, Adenoid. See Lupus miliaris. 

Acne Albida. See Milium. 

Acne Artificialis. By this term is meant an inflamma- 
tion of the sebaceous glands and hair follicles caused by 
drugs either applied l6et0lv or acting from within. 'It has 
three principal varieties, namely, tar acne, bromic acne, and 
iodic acne, and should be regarded rather as a dermatitis 
medicamentosa than as an acne. Tar produces acne-like 
lesions with black points when applied locally to some sus- 
ceptible skins. As a rule, papules are more abundant than 
pustules, but abscesses and furuncles may form. These 
lesions are not confined to the usual locations for acne, are 
particularly abundant on the extensor surface of the arms, 
and are recognizable by their central black points and by 
the fact that the patient is using tar. For its cure all that 
is necessary is to stop the use of the tar and to soothe the 
inflamed skin. None of these acnes is a true one. Bromic 
and iodic acnes will be spoken of under drug eruptions. 
Derivatives of tar, chrysarobin, and pyrogallol may also 
produce similar acne-like lesions when applied externally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to acne necrotica. The first needs no descrip- 
tion ; the second will be found further on. 

Acne Cachecticorum is rather to be regarded as a scrof- 
uloderm than an acne, as it probably has little to do with 



ACNE. 79 

the sebaceous glands. It occurs in broken-down or scrof- 
ulous subjects, and is particularly prone to appear upon 
the extremities, though it may be disseminated over the 
whole body. It takes the form of small, congested or 
dark-red, sluggish, flat papules and papulo-pustules that 
run a slow course, break down, perhaps ulcerate, and leave 
small depressed cicatrices. They may aggregate into 
patches. Occurring on the fingers, these will often be con- 
gested and clubbed. The lesions may appear in crops. It 
occurs in children as well as in adults. It is one of the 
rare forms of the disease, and requires tonic remedies such 
as cod-liver oil and iron for its cure. 

Acne Cornea. See Keratosis follicularis. 

Acne* Fluente. See Seborrhoea oleosa. 

Acne Follicularis. See Comedo. 

Acne Frontalis. See Acne necrotica. 

Acne Hypertrophica. See Rosacea. 

Acne, Iodic and Bromic. See Dermatitis medicamentosa. 

Acne Keloid. See Dermatitis papillaris capillitii. 

Acne Keratosa. H. R. Crocker * describes this disease 
as an eruption of finger-nail sized, well-defined, excoriated 
patches covered with blood crusts located on the cheeks 
and chin, specially near the mouth. It leaves white, hard 
scars. It is usually a symmetrical eruption, but the lesions 
may come out singly or in very small numbers at irregular 
intervals. The individual lesion begins as a red, firm, 
tender nodule upon which a pustule forms and dries into 
a scab. Imbedded in the lesion are one or more horny or 
soft conical plugs about one-twelfth of an inch long, which 
give rise to irritation until removed. When removed the 
lesion heals slowly after weeks or months. The disease 
is chronic, showing no tendency to recovery. Thus far, 
treatment has been unavailing. 

Acne Medicamentosa. See Dermatitis medicamentosa. 
1 Brit. Journ. Pennat., 1899, xi., 1. 



80 DISEASES OF THE SKIN. 

Acne Mentagra. See Sycosis. 
Acne Miliaris. See Milium. 

Acne Necrotica. Synonyms : A. frontalis ; A. varioli- 
formis ; A. pilaris ; Acne rodens ; A. ulcereuse ; A. arthri- 
tique ; A. miliaire scrofuleuse ; Lupoid acne. This dis- 
ease has been most carefully studied by R. Sabouraud, 1 
and from his description this article is taken. 

The disease begins as a vesicle about a hair follicle. In 
two or three days the vesicle has attained a diameter of three 
millimeters, and is round, flat, umbilicated, and slightly raised 
above the skin. Its contents have become cloudy and it 
is surrounded by a very circumscribed inflammatory areola 
which soon disappears. It soon dries up, without opening 
spontaneously, into a crust that seems let into the skin like 
a favic crust. The crust is at first yellowish but soon be- 
comes brown. If the crust is raised, it discloses a deep, 
cup-shaped depression with rugose walls. There is a deli- 
cate layer of pus between the crust and the bottom of the 
depression. Left to itself, the crust falls after many weeks, 
leaving a large, red, dry depression, which after a time 
becomes white and remains hairless, the hair usually fall- 
ing with the crust. Sometimes the original crust enlarges 
by the formation of a second vesicle about the first, or two 
vesicles near each other may fuse. If scratched, they 
may become impetiginous. The sites of predilection for 
the disease are the nose, temples, forehead, between the 
shoulder-blades, and over the breast bone. It is most 
often seen on the temples, and may spread on the scalp or 
bearded portion of face, causing destruction of the hair. 
It is not seen before puberty, and continues indefinitely or 
by relapses in one place or in several, often symmetrical 
regions. The resulting cicatrices are very disfiguring, 
and resemble those of variola. 

Etiology. The cause of the disease is not determined. 
Sabouraud believes that a seborrhceal skin is the pre- 
disposing factor, and that a special micro-bacillus is the 
cause of the disease. The staphylococcus aureus is also 
found in connection with the disease. 

1 Ann. de derm, et de syph. , 1899, x., 841. 



ACNE. 81 

Pathology. J. A. Fordyce 1 finds that the disease 
begins in and about the hair follicles above the entrance 
of the sebaceous glands. As the inflammatory process 
extends it involves the sebaceous glands as well as the 
superficial portion of the derma, resulting in a necrosis of 
the pilosebaceous system. In one case he found enormous 
numbers of staphylococci in the lymph spaces and free in 
the tissues. 

Diagnosis. In some cases the resemblance to syphilis 
is striking, but the extreme chronicity of it and its occur- 
rence along the hair line distinguish it, as well as its 
general course of development. 

Treatment. The ointment of the ammoniate of 
mercury is efficient in many cases. Sulphur, salicylic acid, 
and resorcin are also useful. Curetting is also of service. 
Sabouraud thinks that for the disease when it invades the 
scalp the best remedy is pyrogallol, either with or without 
tar or sulphur, fifteen per cent, in ointment or six per cent, 
in ethereal oil. He also advocates the daily use of alcohol 
with a little iodine or bichloride of mercury for three 
months after the disease is apparently well. 

Acne Pilaris. See Acne necrotica. 

Acne Punctata. See Comedo. 

Acne Rodens. See Acne necrotica. 

Acne Rosacea. See Rosacea. 

Acne Scrofulosorum. See Acne cachecticorum. 

Acne Sebacea. See Seborrhcea. 

Acne Syphilitica. See Pustular syphiloderm. 

Acne Tuberculoide. See Molluscum contagiosum. 

Acne Ulcereuse. See Acne necrotica. 

Acne Urticata is the name given by Kaposi to a chronic, 
itching disease occurring on the face, scalp, hands, and, 
usually, on the extensor surfaces of the extremities. It 
begins as an acute eruption of bean or larger sized, pale- 
red, very hard, wheal-like elevations which within a few 
1 Joum. Cutan. and Gen.-Urin. Dis., 1894, xii., 152. 



82 DISEASES OF THE SKIN. 

hours to four days undergo involution. They are usually 
scratched and broken. They leave flat, brown, cicatricial 
stripes corresponding to the scratches. The itching is so 
severe as to interfere with sleeping. 

Acne Varioliformis. See Molluscum contagiosum and 
Acne necrotica. 

Acnitis. See Granuloma necrotica. 

Acrochordon. See Fibroma. The term is also applied 
to large or small polypoid prominences produced by an 
overgrowth of the endothelium of the sebaceous glands. 
These occur in elderly people upon the eyelids and neck. 
They may attain the size of hazelnuts and look like over- 
grown milia. The treatment consists in removing them 
by ligature or scissors. 

Acrodynia is a disease closely allied to pellagra in its 
symptoms, that has been observed chiefly amongst French 
and Belgian soldiers, and is probably due to some defect 
in food supplies. It begins with gastro-intestinal irrita- 
tion, to which certain neuroses soon add themselves, such 
as formication, hyperesthesia, and anaesthesia. An ery- 
thema of the hands and feet, and it may be of the whole 
body, followed by desquamation or by brown or black 
pigmentation, is the cutaneous element of the disease. 
Recovery usually takes place, though death may occur 
from diarrhoea. 

Acromegaly. A disease characterized by overgrowth of 
the bones and soft tissues of the face, hands, wrists, and 
feet. It is a rare condition and is allied to elephantiasis. 
It is a progressive and, usually, symmetrical disease, and 
at times attains immense proportions. The skin becomes 
dry and harsh, yellowish and wrinkled. Fibromata may 
develop. Symptoms of nervous derangement are also 
present. The cause is unknown and treatment is of no 
avail. 

Actinomycosis. While this is usually a disease of cattle, 
in which it causes tumors of the jaws, it may attack man 
and produce nodular tumors with fistulous openings. It 



ADENOMA. 83 

is due to the invasion of the tissues by the ray fungus. 
Infection usually occurs by the mouth along a carious 
tooth, but it may take place through the digestive tract, 
the lungs, and, rarely, by an abrasion of the skin. The 
incubation period is about four weeks. The tumors bear 
a strong resemblance to sarcoma and are livid or bluish 
red. At first firm, they after a time soften and break 
down and discharge through a fistulous tract, at first a 
purulent, afterward a sanious material, in which are numer- 
ous yellow granules, from pinhead to hemp-seed size. The 
disease runs a chronic course. Its prognosis is bad. Iodide 
of potassium in ten- to fifteen-grain doses three times a day 
is well spoken of by M. Morris, 1 and may be combined 
with the insertion into the sinuses of a one per cent, solu- 
tion of the same drug. If this fails, surgical procedures 
may be resorted to. 

Addison's Keloid. See Morphoea. 

Adeno-carcinoma is a carcinoma originating in the glands 
of the skin, most often in the sweat glands. 

Adenoma. These are glandular tumors, and are due to 
a proliferation of the lining cells of either the sebaceous or 
sweat glands. There are, therefore, two varieties : A. 
sebaceum and A. sudoriferum. Though met with in per- 
sons of mature years, it is not improbable that they are 
congenital defects. They form solid tumors from pinhead 
to egg size or larger. They may remain stationary or 
grow ; may disappear spontaneously, ulcerate, form cysts, 
or undergo hyaline, colloid, or fatty degeneration. While 
usually benign, they may become malignant. They tend 
to relapse after extirpation. 

The sebaceous form is encountered most often on the 
face, about the nose and mouth ; less frequently upon the 
scalp, but may occur anywhere. The color of these ade- 
nomata varies from pale yellow to red, when they will 
have fine telangiectases over them. They occur most 
often in women, are generally multiple, often with an 
uneven surface, and seated deep in the skin. Pollitzer 
i Lancet, 1896, 1, 1553. 



84 DISEASES OF THE SKIN. 

has cured one case of the sebaceous variety by means of 
multiple scarifications. 

The sudoriferous variety occurs upon the head, neck, 
and extremities as dirty grayish-white tumors, sometimes 
in groups, with uneven, often knobby surface. They are 
rare lesions of the skin, difficult of diagnosis, and require 
extirpation or total destruction for their cure. Most cases 
formerly described under this heading are now regarded 
as cases of multiple benign cystic epithelioma, which see. 

Ainhum is a disease most frequently seen in the 
negro race, though a number of cases have been reported 
from India. It is seen in men more often than women, 
and several members of the same family have been known 
to be affected by it. The little toe of one or both feet is 
the one usually diseased, though the other toes do not 
always escape. It begins as a furrow on the inner and 
lower side of the proximal end of the toe, which gradually 
extends outward and upward so as to encircle the whole 
toe at its juncture with the foot. In the meantime the toe 
becomes enlarged, separates from its next neighbor, and 
rotates outward. When fully developed the toe wobbles 
about so that it interferes with walking. The whole 
process is unattended with ulceration, except accidentally 
caused and after the disease has lasted a longtime. When 
it occurs the toe fills off. There is little pain experienced 
till near the end of the disease. It takes from one to 
fifteen years for the full development of the disease. The 
cause is unknown, though traumatism probably plays a 
part. The process is one of progressive degeneration and 
destruction of all the elements of the toe — skin, muscles, 
bone. In its early stage a deep incision perpendicular to 
the direction of the furrow may check its course. Later, 
amputation is required for the cure, and healing takes place 
rapidly. 

Albinism. See Leucoderma. 

Aleppo Boil, Aleppo Bouton, or Aleppo Evil, is an ill-de- 
fined furuncular disease occurring in Syria and the Levant, 
where it is endemic and widespread. One or more pea- 
or bean-sized pustules appear that slowly grow and ulcerate 



ALOPECIA. 85 

indolently. Large ulcerating, granulating patches may 
form. The extremities and face are the parts most often 
affected. All ages and conditions contract the disease. 
One attack usually protects against subsequent infection. 
Treatment is not very satisfactory. Painting the papules 
with tincture of iodine is recommended. Ulcers are to be 
treated on surgical principles. 

Algidite Progressive. See Sclerema neonatorum. 

Algor Progressivus. See Sclerema neonatorum. 

Alopecia. Synonyms: Calvities ; (Fr.) Alopecie; (Ger.) 
Kahlheit ; (Ital.) Calvezza ; (Sp.) Calvez ; Baldness. 

By alopecia is meant a partial or general loss of the 
hair, so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely : Alopecia adnata ; 
Alopecia senilis ; Alopecia prematura or presenilis ; and 
Alopecia areata. 

Alopecia Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. The newborn child is covered with long, 
dark hair which soon falls to give place to fine lanugo 
hairs ; or this change has taken place before birth, the 
usual course of events, and at birth lanugo hairs only are 
present. In alopecia adnata there is not the slightest trace 
even of lanugo hairs either on the scalp or eyebrows. In 
some cases the baldness is not so complete. Most cases, 
after months or years, recover either altogether or partially, 
but in some cases the hair never grows. In pronounced 
cases delayed dentition or deficiency of the teeth has been 
observed. 

Etiology. The cause of the disease is arrest of the 
development of the hair, probably due to an error in in- 
nervation. It is said to be hereditary in some families. 

Pathology. There is a complete absence both of hair 
and hair papilla?. There are some abortive hair follicles. 
Otherwise the scalp is normal. 

Teeatment. The treatment is mainly an expectant 
one. The nutrition of the child should be looked after 
and the scalp kept in a healthy condition. If this expect- 



86 DISEASES OF THE SKIN. 

ant plan does not satisfy the child's attendants, some of 
the stimulating hair washes, as in alopecia presenilis, may 
be prescribed for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing 
years. Any loss of hair commencing about the forty-fifth 
year and without apparent cause may be placed under 
this heading. Graying of the hair may have preceded it 
for several years or may be coincident with it. Or the 
hair may fall without becoming gray. The hair fall having 
once begun is progressive, though its rate of progress may 
be slow or fast. It usually shows itself first upon the 
vertex of the head, forming the tonsure, which slowly in- 
creases in size and, moving forward, renders the whole top 
of the head bald. Or it may begin anteriorly and move 
backward. Or the hair on the whole top of the head may 
become thinned at once. Rarely are the temporal and 
occipital regions bald, and an island or tuft of hair is 
sometimes preserved for a long time in the middle frontal 
region. The hair fall is always symmetrical and the bare 
scalp is smooth, oily, shiny, and appears as if stretched. 
Not only does the hair fall from the scalp, but it may fall 
from the axillae and pubic region ; these manifestations I 
believe to be more common in women than men. Very 
rarely does the beard fall. 

Etiology. The cause of this form of baldness is a 
progressive atrophy of the scalp. Men are far more prone 
to the disease than are women. 

Treatment. As to the treatment we can do nothing. 
Prophylaxis, as described under Alopecia prematura, will 
delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia prcematura idiopathica arises without any evi- 
dent disease of the scalp or disorder of the general health. 
It usually begins in early life, between twenty-five and 
thirty-five ; it may begin as early as the eighteenth year. 
Its general course is the same as the senile form of alopecia. 
Very often the upper parts of the temples are earliest 
affected, the hair line receding. In those who part the 



ALOPECIA. 87 

hair in the middle, the thinning of the hair about the part 
may be the first thing to attract attention. The process 
of the hair fall is one of progressive thinning of the indi- 
vidual hairs at first, and then of the whole quantity of 
hair, so that strong hairs give place to lanugo hairs, and 
these in turn fall and leave bald places. At the same time 
a progressive tightening of the scalp upon the skull will 
be observable in some cases, the scalp having lost that 
cushion of fat that is under it in early life. The hair fall 
having begun is progressive, though years may elapse 
before there is absolute baldness. The tonsure may not 
enlarge for a long time, and then increases rapidly in size. 

Etiology. The main cause of this form of baldness 
is heredity. Fathers and sons for generations may grow 
bald early, or the inherited peculiarity may have to be 
traced to the grandparents or some collateral line. Not 
all the children of one family in which baldness is heredi- 
tary are bald, but it will manifest itself in two or three of 
the children. According to Pincus, 1 inheritance and 
chronic eczema or an impetiginous eruption on the scalp 
in the years preceding puberty are the only predisposing 
causes of baldness. Insufficient or improper care of the 
scalp ; daily sousing of the hair with water, combined with 
improper drying of the hair afterward ; sweating of the 
head, either spontaneously or on account of the wearing 
of unventilated or hot head-coverings ; constant mental 
strain, either on account of intellectual work or of worry ; 
the wearing of stiff, unyielding hats ; gout ; all diseases 
lowering the general nutrition ; and dissipation, are all put 
forth by reputable observers as causes of premature bald- 
ness. 

That women are less often bald than men probably 
depends upon several factors : The fatty cushion beneath 
their scalps is longer preserved than in men ; they give 
more attention to the care of the hair and less often wet it ; 
and their hats are soft, ventilated, and fit loosely. 

Treatment. We can do more for this form of bald- 
ness by prophylaxis than by attempts at making the hair 
that has fallen out grow in again. Prophylaxis should 
1 Virchow's Archiv, 1867, xli., 322. 



88 DISEASES OF THE SKIN. 

begin at the beginning of life, and should be continuous. 
This is of special importance in the case of children in 
families prone to early loss of hair. 

The hygiene of the scalp is the chief part of the prophy- 
lactic treatment. Beginning in infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the proc- 
ess of parturition. This should be done by the gentle use 
of soap and water after rubbing in a little sweet almond 
or other bland oil. No force should be used, and after the 
scalp is washed it should be patted dry with a soft, warm 
cloth, and a little oil or vaseline smeared over it. After 
the first washing it should be oiled daily and washed 
every second day. When the hair begins to grow, a soft 
brush alone should be used to arrange it, and the daily 
oiling may be stopped, unless sebaceous matter accumu- 
lates in cakes, in which event the oiling should be con- 
tinued. Sometimes it is well to add a little sulphur to the 
oil or vaseline, but in most cases it is unnecessary. The 
slightest indication of disease of the scalp should be 
promptly and properly dealt with. A child's hair should 
be cut short, not cropped close to the head. After a girl 
has reached her eighth or ninth year the hair should be 
allowed to grow. 

The hair and scalp do not need to be washed more than 
once in two or three weeks, and for this purpose any good 
snap will do, with plenty of water to wash out the soap- 
suds. Borax with water will clean the scalp nicely, but 
its continuous use is injurious. The yolk of three eggs 
beaten up with lime-water makes an elegant shampoo. 
The daily sousing of the head in water should be pro- 
hibited. Deep brushing of the hair with a loug-bristled 
brush of sufficient stiffness to warm, but not scratch, the 
scalp is one of the best agents we have for stimulating 
the scalp. The brushing should be done daily and syste- 
matically. 

Pomades and hair washes should be avoided unless there 
is some evident disease of the scalp. Women should be 
cautioned against pulling their hair into artificial and con- 
strained positions. It is most important that a sufficient 



ALOPECIA. 89 

amount of out-door exercise should be taken to aid in keep- 
ing the patient in good general condition. 

When the hair has begun to fall it is important that the 
hygiene of the scalp should be begun, if not already prac- 
tised. We can do more for our cases in this way than by 
any other method. 

Many remedies have been advised for the curative treat- 
ment of baldness. Pilocarpine, in hypodermic injections 
or in ointment form, has been warmly commended. Las- 
sar l prescribes it as follows : 

R Hydrochlorate of pilocarpine, gr. xxx ; 2 

Vaseline, 3v ; 20 

Lanolin, ad ^ ij ; ad 60 

Oil of lavender, gtt. xxv. 1 66 M. 

It may also be used in the form of the fluid extract of 
pilocarpus, ten to fifteen per cent, strength in dilute alcohol. 
He also advises oil of turpentine, equal parts with an 
indifferent oil or alcohol. It is my experience that most 
of these cases do better with oily than with alcoholic prep- 
arations. Gallic acid, three per cent., in an oily excipient ; 
tar ; galvanism ; massage ; tincture of cantharides (5J-3J) ; 
tincture of nux vomica (3J-5J), and a lot of other irritants 
and essential oils have their advocates. My experience 
teaches me that so-called "hair tonics" are of little value, 
and that the best remedies are attention to the general 
health of the patient, massage to the scalp, and daily, sys- 
tematic and deep brushing of the hair. Pilocarpine is the 
only drug that has shown any decided influence on hair 
growth. 

Peognosis. The prognosis of this form of baldness is 
bad, and especially so if the disease is hereditary and the 
patient is more than thirty years of age. It is better with 
women than with men, as they will give more time to the 
care of their scalps and show less tendency to alopecia. 

Alopecia p?'cematura symptomatica is premature baldness 

in which there is some evident disease of the scalp or 

disorder of the general nutrition of the body to account 

for it. It has four varieties : Alopecia furfuracea seu 

1 Therap. Monatshefte, 1888, No. 12. 



90 DISEASES OF THE SKIN. 

pityrodes, A. syphilitica, Defluvium capillorum, and A. 
follicularis. 

Alopecia Furfuracea seu Pityrodes is the form most fre- 
quently met with and the one in which we can often obtain 
good results by treatment. In my experience seventy per 
cent, of all cases of loss of hair are of this variety. 

Symptoms. In it we have an evident disease of the 
scalp to deal with — that is, dandruff. By this we mean 
either a seborrhcea with fatty crusts, or else a pityriasis 
with more or less abundant scaling. Both these condi- 
tions are now regarded as different forms of eczema sebor- 
rhoicum. 

Alopecia pityrodes has two stages : The first one lasts 
from two to seven years or more, and is attended by a 
greater or less amount of dandruff and by dryness of the 
hair. Then comes the second stage, when the hair falls 
more or less rapidly. Its course may be the same as that 
of the two previously described forms of baldness, though 
more commonly the whole top of the head is affected at 
once, the hair becoming progressively thinner in diameter 
and less in amount until baldness results. As the baldness 
increases the dandruff lessens. The disease is one of early 
life in a large number of cases, often occurring between 
the twentieth and thirtieth year, and affects both sexes. 

Etiology. The cause of the hair fall is the dandruff. 
By this it is not meant that everyone who has dandruff 
will become bald. Everyone's experience is against that. 
But it is true that in certain persons when, on account of 
some error in the nutrition of the sebaceous glands, they 
become diseased, the hair follicles sympathize with them 
and after a time the hair production ceases. Of late the 
opinion is gaining ground that alopecia pityrodes is con- 
tagious, and the experiments of Lassar and Bishop ' ^vould 
seem to prove this. They succeeded in producing typical 
alopecia pityrodes in guinea pigs by rubbing into their 
backs a pomade composed of the scales taken from the 
head of a student who was afflicted with the same disease. 
A number of observers have reported from time to time 
1 Monatshefte f. prakt. Dermat, 1882, i., 131. 



ALOPECIA. 91 

the finding of a parasite in this disease, but as yet no one 
micro-organism can be demonstrated as positively at the 
bottom of the trouble. Sabouraud * believes that the same 
parasite that produces the seborrhoea produces the loss of 
hair. It is according to him a micro-bacillus that grows 
down into the hair follicle between its wall and the hair 
and causes atrophy of the hair papilla. 

Teeatment. The treatment of this form of baldness 
must be addressed to the cure of the seborrhoea or pityria- 
sis that causes the loss of hair. Prophylaxis is here again 
more important than the use of remedies for promoting the 
growth of the hair. The treatment of seborrhoea and pity- 
riasis will be considered under their respective headings, 
and need not be here detailed. My belief is that greasy 
applications are better than those containing alcohol. The 
mistake is frequently made of prescribing tincture of 
cantharides or other irritant because the hair falls. Of 
course, these things, in an already more or less inflamed 
scalp, only do harm. If we can succeed in curing the 
seborrhoea, the hair will take care of itself. If the case 
comes to us before absolute baldness is established, we can 
feel pretty confident that we can stop, or at least delay, 
the fall of the hair. But we must inform our patients 
that it is only by long and persistent treatment that we 
can accomplish anything. 

Lassar's plan of treatment has gained great currency, 
and is as follows : The scalp is to be vigorously washed 
each day with a tar soap that forms plenty of suds. The 
soapsuds are to be washed out with warm, followed by 
cold, water, the scalp dried and anointed with solution of 
bichloride of mercury (2 : 1000). This is to be dried out 
by applying 0.5 per cent, solution of /9-naphtol in abso- 
lute alcohol. Finally, an oil made up of 

R Ac. salicylici, £ss; 2 

Tincture of benzoin, gr. xl ; 3 

Neat's-foot oil, liij ; 100 

is to be applied. The procedure is to be kept up for six 

to eight weeks. I have found few patients who would 

1 Ann. de derm, et de syph., 1897, viii., 257. 



92 DISEASES OF THE SKIN. 

persist in it, and in these I have seen little good result. 
For women it is impracticable. 

Resorcin has been commended. It may be prescribed 
as follows : 

R 



Resorcin, 


gr. xv ; 


3 


Ol. ricini, 


388 ; 


6 


Spts. vini rect., 


ad 3J ; 


ad 100 


Bals. Peruv., 


gtt. ij ; 


gtt. ij. 



Sabouraud recommends the use of a pomade containing 
sulphur, oil of cade, and yellow oxide of mercury on three 
evenings of the week, and on the following mornings to 
wash the scalp with soap and water, and rub with a brush 
charged with a two per cent, solution of resorcin in equal 
parts of alcohol and ether. 

Tar is a good remedy, but it is objectionable on account 
of its odor and color. /9-naphtol, in five to ten per cent, 
strength, and hydrate of chloral in about the same strength, 
may be tried. Sulphur is the most reliable remedy. Its 
efficacy is increased by the addition of ten to fifteen per cent, 
of the extract of pilocarpus, and the best way of using 
sulphur is in unguentum aquse rosae or cold cream. Further 
particulars in regard to the treatment of the seborrhoea will 
be found under the section upon that subject. When there 
is absolute baldness it is questionable if anything will make 
the hair grow. 

Alopecia Syphilitica may be an early or late manifesta- 
tion of syphilis ; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 
temporary hair fall, or as a localized, destructive, and per- 
manent one. 

Symptoms. The former variety occurs early in the 
disease, and is a thinning of the hair in irregularly shaped 
patches scattered over the scalp, giving to it an appearance 
similar to what would be produced by cutting the hair 
carelessly with a dull pair of shears. In rare cases we 
may have a general loss of hair from all hairy regions. 
The broken arch of the eyebrow is always suggestive of 
syphilis. There may be some seborrhoea with this form 
of alopecia. 



ALOPECIA. 93 

Localized baldness is one of the later manifestations of 
syphilis, and is always preceded by a destructive disease 
of the scalp. The bald spots will vary in size with the 
extent of the destructive process, which may be one of 
absorption or ulceration. 

Diagnosis. The diagnosis of syphilitic alopecia is 
made by observing the irregular shape of the patches and 
that they are not completely bald, and by the occurrence 
of the broken arch of the eyebrow. These should arouse 
suspicion, when other symptoms of the disease will be 
found. It most resembles alopecia areata, but in this dis- 
ease the patches are perfectly circular or oval and entirely 
bald. 

The baldness due to destructive forms of syphilis can 
be confounded only with that of favtis. In the latter dis- 
ease the scalp preserves a reddish color for a long time, 
and then assumes an atrophic, smooth, cicatricial look, 
which is characteristic of it. The history of the two 
cases is very different, as in favus we do not have ulcer- 
ation, and we do have cupped, sulphur-yellow crusts. 
Favus is also more widespread and disseminated than is 
late syphilis of the scalp. 

Treatment. The treatment of this form of baldness 
is that of the underlying disease. A mercurial ointment 
or an oil containing the bichloride may aid in hastening 
the new growth of the hair in the early form of baldness. 
The late form may be lessened by active constitutional 
and local treatment, according to the general principles 
laid down for the management of syphilis. 

Defluvium Capillorum is that sudden and general fall and 
manifest thinning of the hair which come on during or 
after some severe illness, such as parturition, fevers, mer- 
curialism, and various cachexia?. 

Symptoms. Rarely does it produce complete baldness. 
The fall is usually rapid and takes place during con- 
valescence or after recovery, rather than during the 
course of the disease. It may not occur until three 
months after the illness. Seborrhoea may or may not be 
present. 

Etiology. The cause of the hair fall is the profound 



94 DISEASES OF THE SKIN. 

disturbance of the nutrition of the body, in which the hair 
sympathizes. 

Treatment. The treatment is rather to be addressed 
to the patient than to the hair. If we can succeed in 
building up the patient's strength, the hair will take care 
of itself. The scalp should not be shaved. Local treat- 
ment is the same as in alopecia pityrodes. 

Alopecia Follicularis is baldness due to some disease of 
the scalp that either destroys the hair follicles or impairs 
the proper performance of their function. A history of 
the causative disease may be obtained, or the disease itself 
will be present. Impetigo ; long-continued sycosis ; inflam- 
matory diseases, such as erysipelas ; parasitic diseases, such 
as favus and ringworm ; and destructive new growths, such 
as syphilis and lupus, all may cause alopecia follicularis. 

The etiology, diagnosis, prognosis, and treatment of this 
form of baldness are the same as the disease that gives rise 
to it, for which we must refer to the proper sections. 

Alopecia Areata. Synonyms : Area celsi ; Area occi- 
dentalis diffluens, seu serpens, seu tyria ; Alopecia circum- 
scripta ; Porrigo seu tinea decalvans; Vitiligo capitis; 
Ophiasis; Phyto-alopeeia ; (Fr.) Teigne pelade; Pelade; 
(Ger.) Die kreisfleckige Kahlheit ; Circumscribed baldness. 

This form of baldness usually begins suddenly, the pa- 
tient discovering by accident, or being told by someone, 
that he has a bald spot. Sometimes, on waking in the 
morning, the patient is astonished to find loose hairs in 
his bed, and, on looking in the glass, to see that he has a 
bald patch on his head. In some cases the hair fall may 
have been preceded for days or weeks by neuralgic pains 
in the head. In most people there are no premonitory 
symptoms, and, apart from the bald spots, no discomfort 
on the part of the patient nor cutaneous lesions. The 
neuralgia may continue after the hair fall or it may cease. 
There may be but one bald patch or there may be a dozen 
patches. A patch may be as small as a three-cent silver 
piece or as large as a silver dollar. If larger — and the 
whole head may be completely bereft of hair — the patch 
is formed by the coalescence of several smaller ones. A 



ALOPECIA. 



95 



patch may attain its fall size at once or it may slowly en- 
large, spreading at the periphery. The patches are more 
or less perfectly oval or circular in shape and sharply de- 
fined against the surrounding hair. Patches formed by 
the coalescence of other patches lose the oval outline and 
may have a scalloped border. The color is usually that 
of the normal scalp ; it may be pale or hypersemic. The 
patch is perfectly bare and smooth, without scales, as a rule. 
Sometimes it is dotted over with short, broken hairs, old 
roots that soon fall out. Sometimes it looks as if it were 



Fig. 9. 




Alopecia areata. 

depressed, an appearance due to falling out of the hair 
roots. Sometimes there is more or less seborrhceal der- 
matitis of the scalp. Any or all the hairy regions of the 
body may be affected, the patient sometimes being entirely 
denuded of hair. Most often it is the scalp that suffers, 
especially the temporal and occipital regions. The bearded, 
portion of the face may be affected alone. Around the 
border, of a recent patch the hair is loosened so that it may 
be readily extracted. The sensibility of the skin may be 
diminished. Generally it is preserved. 

The course of the disease is chronic, with a strong 



96 



DISEASES OF THE SKIN. 



tendency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 
growth of a fine down upon the bald patch. This will 
fall out and be replaced by lanugo hairs that in their turn 
will fall out to be replaced by stronger hairs, until normal 
hairs grow at last, though these at first may be white. 
Some cases relapse year after year; in some cases the hair 
never grows beyond the lanugo stage ; and some cases re- 
main permanently bald. 

Fig. 10. 




Alopecia areata 



Etiology. The subjects of the disease may be in ap- 
parently perfect health, but not infrequently they are of 
very nervous temperament, exhausted by overwork or 
nervous strain, or out of health in some way. Beth sexes 
are affected, the male sex rather more than the female. 
It occurs very often in children. Thus Crocker, who has 
a large experience with children, met with it in children 
under twelve years old thirty-seven times out of eighty- 
three cases. The youngest case reported was at two years 
of age, and cases have been seen as late as in the sixtieth 
year. It is rather more frequent among the poor than 
among the well-to-do. It is more frequent in some coun- 
tries than in others. Thus Crocker's tables show that in 
1 By the courtesy of Dr. S. Dana Hubbard, 



ALOPECIA. 97 

London it forms two per cent, of all skin cases ; Bulkley's 
tables show but a little more than one-half per cent, in 
New York. 

The disputed points in the etiology of alopecia areata 
are its contagiousness, and whether it is a neurosis 01 a 
parasitic disease. At the present time it is impossible to 
decide with absolute certainty which of the contending 
parties is right. Most instances of contagion have been 
reported by French observers whose diagnostic skill we 
can hardly call in question. They have reported instances 
in which a large number of cases have appeared in bar- 
racks or schools, and from there spread to neighboring 
towns. In England similar apparent epidemics have been 
reported, but as a fungus indistinguishable from the 
trichophyton fungus was found in the surrounding hairs 
they were doubtless instances of bald ringworm. It is 
possible that some of the French epidemics were of simi- 
lar character. In this country one epidemic apparently of 
alopecia areata has been reported by Putnam. 1 The cases 
were examined by Drs. J. C. White and J. T. Bo wen, of 
Boston, who agreed in the diagnosis. Nothing suggestive 
of trichophytosis was found. Isolated instances of ap- 
parent contagion have been reported by various physicians. 
Certainly the body of experience is against the contagious- 
ness of the disease. Besnier and Doyon, 2 who believe 
firmly that the disease is contagious, think that it is trans- 
mitted most often by means of the barber's utensils, espe- 
cially the patent hair clippers, and that it is impossible in a 
great number of cases to trace the contagion. Hutchinson 
and some other English authorities are inclined to the 
belief that in many cases ringworm preceded the appear- 
ance of the bald spots at a greater or less interval. 

As to the parasitic origin of the hair fall, it is not yet 
proven. A goodly number of skilled microscopists have 
described the fungus, but they do not agree among them- 
selves. Still, it is assumed that a micro-organism will be 
demonstrated at some time. O. Lassar 3 thinks that the 

1 Arch. Pediat., 1892, ix., 595. 

2 Path, et Trait des Mai. de la Peau : Kaposi. French edition, 
Paris, 1891. 3 Dermat. Zeitschrift, 1900, vii., 809. 



98 DISEASES OE THE SKIN. 

phenomenon can be best explained on the theory of a virus 
due to a micro-organism. 

This leaves only the neurotic theory. Many derma- 
tologists believe the disease to be a tropho-neurosis. It 
has been known to follow blows or injuries to the head, 
moral or mental shock, operations on the neck, and, experi- 
mentally, injury to or extirpation of the second cervical 
ganglion in cats. 

Perhaps the disease should be regarded rather as a 
symptom due to a disturbance of the nutrition of the hair 
depending sometimes on mierobic infection, at other times 
on a tropho-neurosis. For the present no decisive answer 
can be given to the question : " What is the cause?" 

Pathology. Though hairs taken from the margin of 
an advancing area show atrophic changes, there is noth- 
ing distinctive about such changes. A. R. Robinson 1 
found evidences of inflammation, and some round-cell in- 
filtration confined principally to the perivascular region. 
In recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. 
In recent cases the hair follicles were either without hair 
or contained a lanugo hair or a hair just about to fall. 
The hair-roots, where present, showed atrophic changes. 
In advanced cases the sebaceous glands were degenerated 
or had entirely disappeared. In the worst cases there was 
complete atrophy of the hair follicles and of the subcu- 
taneous fatty tissue. He also describes the presence of 
various cocci in the lymph spaces of the corium and the 
walls of a few of the vessels, which he regards as the 
cause of the disease. Sabouraud 2 in making his exhaustive 
studies of ringworm, Avas led to investigate alopecia areata. 
The characteristic hair in the disease has the shape of an 
interrogation point. The upper part is normal and pig- 
mented, while the lower part is atrophied and devoid of 
pigment. He found in the upper third of the diseased 
follicles an ampullar swelling which he names the utricle 
peladique. This is filled with compact clusters of 

1 Monatsliefte f. prakt Dermat., 1888, vii., 409. 

2 Ann. de. derm/et de syph., 1896, vi., 253. 



ALOPECIA. 99 

micro-bacilli, the smallest known. These microbes he 
regards as the probable cause of the disease. They gain 
access to the follicles and set up a reaction, followed by 
atrophy of the hair follicles and papillae. The disease is, 
therefore, one of the follicles and not of the hair. Sabou- 
raud's views have not been generally accepted as yet, nor 
does he regard the case as closed. 

Diagnosis. A typical case of alopecia areata is so 
peculiar that there is little danger of mistaking it for 
anything else. It differs from trichophytosis capitis in its 
sudden onset, its perfectly bare, smooth, non-scaly surface, 
without broken, split, and gnawed-off hairs, and in the 
absence of the trichophyton fungus from the hair and 
scales taken from the neighboring parts. In bald ring- 
worm patches, which resemble alopecia areata, the fungus 
will be found in the neighboring hair, or some character- 
istic "stumps" will be found on the scalp. In adults 
ringworm of the scalp is very rare. It differs from favus 
in the absence of cupped crusts at any time in its course, 
in the scalp not presenting that cicatricial appearance 
always met with in favic baldness, and in complete absence 
of fungous growth. 

The baldness due to syphilis may resemble that of alo- 
pecia areata, but other symptoms of syphilis will be pres- 
ent, and there will never be a history of the formation of 
well-defined oval or circular areas. Lupus erythematosus 
at times affects the scalp and produces circumscribed bald 
areas; but these are not oval or round, and the skin is red 
and scaly, and evidently cicatrized. The alopecie innom- 
inee of Besnier is extremely difficult to diagnose from alo- 
pecia areata. It differs in not forming regular oval or 
round bald areas, but rather irregular ones, with clumps 
of hair at their borders ; in having a cicatricial appear- 
ance, and in presenting, at first at least, some evidences of 
dermatitis or folliculitis. This type of baldness has not 
yet become well' recognized. 

Treatment. In a disease that is essentially self-limited 
it is hard to estimate how much good our remedies do. 
One duty we have without perad venture, and that is, to 
look after the general condition of the patient. A large 



LofC. 



100 DISEASES OF THE SKIN. 

number of the cases require a stimulating and tonic treat- 
ment — iron, quinine, strychnine, arsenic, cod-liver oil, or 
hypophosphites. Children should be taken out of school 
and allowed to run free. Our hardest task will be to man- 
age those nervous patients who are ever a trouble to us. 

As far as local treatment is concerned, it may be summed 
up in two words : patience and stimulation. As many of 
our parasiticides are stimulating to the skin, they may be 
used with benefit whether we believe in the parasitic cause 
of the disease or not. 

The stronger water of ammonia dabbed on to the scalp 
by means of a swab, care being taken to guard the eyes, 
will be beneficial in some cases. It is remarkable how 
little reaction this powerful remedy will cause in alopecia 
areata. Pilocarpine, in hypodermic injections, or in oint- 
ment form, is at times beneficial, combined with sulphur 
ointment and well rubbed in. I have seen the hair come 
back promptly in a few cases so treated and of normal 
color. Painting the scalp with acetic acid until it whitens, 
and then sponging off with cold water, and repeating every 
three or four days ; chrysarobin, fifteen to thirty grains to 
the ounce, well rubbed into the scalp once a day ; carbolic 
acid (95 per cent.) applied every two weeks or so to small 
areas at a time; the bichloride of mercury, two to four 
grains to the ounce in alcohol, or oleum pini sylvestris ; 
the oleate of mercury, in the strength of two to ten per 
cent. ; blistering with cantharides, or 33^ per cent, of 
iodine in collodion ; and galvanism, have one and all been 
fallowed by the return of the hair. 

Moty ' reports good results from hypodermic injections 
of bichloride of mercury, injecting five or six drops of an 
aqueous solution (1 : 500) into many places about each 
patch. In a later number of the same journal he an- 
nounced that he then used a four per cent, solution of the 
mercury, with a two per cent, solution of cocaine; that he 
made but a single-drop injection in a medium-sized patch, 
and four or five injections about a large patch, and at its 
periphery. Pauses of four days were taken between the 
injections, and a cure is expected after the fourth series. 
1 Ann. de derm, et de syph., 1891, ii., 406. 



ALOPECIA. 101 

Scheffer l is also an advocate of bichloride injections. He 
first rubs the patch with 90 per cent, alcohol. He then 
draws into the syringe 1 c.c. of 1 : 1000 solution of bi- 
chloride of mercury ; then 1 c.c. of 0.5 per cent, solution 
of pilocarpine ; and then \ c.c. more of the bichloride. 
He injects this as horizontally as possible beneath the skin 
of the patch at its edge and repeats at one centimetre dis- 
tance, using about twelve injections for a patch the size of 
a silver dollar. This is repeated in four or five days. 
The hair begins to grow in about three weeks. 

Sabouraud 2 advises in single-patch cases cutting the 
hair short, epilating about the patch, and rubbing the 
patch every second day with one part of Bidet's vesi- 
cating liquid and three or four parts of chloroform. 
Every morning the whole scalp is to be rubbed with 



R Alcohol, camphorat., %iv ; 125 

Spts. terebinthinae, gv ; 25 

Aquae ammoniae, ^j ; 5 



M. 



If the patch is very large, instead of the cantharidal 
solution use 

R Ac. acetici crystal., gr. i-iij : .065-194 

Chloral., 3j ; 4 

^Ether., gj ; 32 M. 

From time to time the patch should be shaved as the 
young hairs come in, while the strength and the number 
of applications of the strong solution should be lessened. 
In obstinate cases he applies a blistering fluid at night to 
a limited area, opens it the next morning and paints the 
surface with nitrate of silver solution. The surface is to 
be covered with absorbent cotton. This is to be repeated 
every week. 

Lactic acid in 50 per cent, aqueous solution is highly 
commended by Balzer. 3 Alcohol or ether is to be used 
first to remove the fat from the part, and then the acid is 

1 Med. moderne, May 19, 1900. 

2 Diagnostic et traitement de la pelade et des teignes del' enfant. 
Paris, 1895. 

3 Monatshefte f. prakt. Dermat., 1900, xxx, 43. 



102 DISEASES OF THE SKIN. 

to be rubbed in with a tampon until the scalp reddens. 
Use daily. If reaction is too great, omit for a few days 
and use borated vaseline. A cure may be expected in two 
to three months. 

It is advisable to pluck the loose hairs from around the 
patch for a zone of perhaps an eighth or a quarter of an 
inch. Every few days slight traction is to be made on 
the hairs surrounding the patch and all the loose ones 
pulled. Massage is also useful. 

Prognosis. Even if left to itself, the chances are that 
the hair will grow in again. This good prognosis should 
be guarded when the patient is past middle life and in 
those malignant cases in which there is complete baldness 
that has lasted several years. 

Alopecia Circumscripta. See A. areata. 

Alop^cie Innominee. See Folliculitis decalvans. 

Alphos. See Psoriasis. 

Anaesthesia is a loss of sensation in the skin which 
occurs in a number of diseases of the nervous system, 
notably in hysterical affections. It may be general or 
partial, or affect but one-half of the body. There may 
be loss of sensibility to pain while the tactile sense is pre- 
served (analgesia), or intense pain with loss of ordinary 
sensibility {anaesthesia dolorosa). There are many sub- 
stances which, locally applied, will cause anaesthesia, such 
as carbolic acid, cocaine, aconite ; and many others which 
will abolish sensation when taken internally. The subject 
belongs to the domain of the neurologist. 

Anatomical Tubercle. See Tuberculosis verrucosa cutis. 

Angio-keratoma l is the name given by Mibelli to a 
peculiar disease of the skin of the hands, feet, and ears 
that has been called telangiectatic warts, or vermes telan- 
giectasiques. 

Symptoms. It follows chilblains or exposure to cold, 
and affects principally the dorsal aspects of the hands and 
feet, though their plantar surfaces may be involved to a 
1 Brit. Journ. Dermat., 1891, iii., 237. 



ANGIOKERATOMA. 103 

slight degree. The eruption consists in tiny, almost im- 
perceptible, pink points that do not disappear on pressure ; 
of pin-point to pinhead sized darker spots that can be 
made almost to disappear on pressure, leaving a deep-red 

Fig. 11. 




Angiokeratoma. (Mibelli.) 

capillary loop in the center; and of clustered telangiectatic 
points forming small irregularly shaped, slightly elevated 
groups. These groups may be as large as a split pea or bean ; 
they may project for half a line above the surface, are hard, 
rough, warty-looking, and of dull purplish-brown color. 
Pressure upon them brings out the telangiectatic character of 
the growths. When pricked with a needle free hemorrhage 
takes place. The eruption is symmetrical as a rule, and 
usually aifects more than one member of a family. It 



104 DISEASES OF THE SKIN. 

begins in early life usually, though it may occur later. 
There are no subjective symptoms. 

Pathology. J. A. Fordyce 1 found in his case that the 
lesions were composed of lacunar spaces filled with blood, 
occupying the papular portion of the derma. He thinks 
that the vascular changes are primary. 

Treatment. The treatment that proves most bene- 
ficial is destruction by electrolysis. 

Angioma Pigmentosum et Atrophicum is the name pro- 
posed by R. W. Taylor for the xeroderma of Kaposi, and is 
described in this book under Atrophoderma pigmentosum, 
which see. 

Angioma Serpiginosum. This is a rare disease, of which 
but few cases have been reported. White 2 describes the 
disease as beginning as minute papules that slowly increase 
to the size of a pea and then undergo spontaneous involu- 
tion in the central portions, while they spread outward in 
an annular form to an indefinite extent and for an indefi- 
nite period. By the end often years the circinate patches 
may be no larger than one or two inches in diameter. The 
margin of the rings is elevated and of uniform breadth. 
New foci continually develop at a distance of one-eighth 
to one-third of an inch beyond the older areas. These, in 
turn, are converted into rings in the same way. The 
lesions are firm and smooth and are of bright-red to claret 
color. The center of the rings is not elevated, and remains 
of a dull pinkish-brown tint. There are no subjective 
symptoms. White's case was on the right shoulder. Other 
cases have been on the arm, cheeks, and legs. 

Most of the cases develop in early life. The pathology 
is undetermined. In White's case the growths were com- 
posed mostly of endothelial cells and the disease was 
thought to be of sarcomatous nature. Electrolysis or de- 
struction by cauterization is to be used in the treatment of 
the disease. 

Anhidrosis or Anidrosis. By this is meant an affection 
of the sweat glandular apparatus attended by a diminution 

1 Journ. Cutan. and Gen.-Urin. Dis., 189G, xiv., 81. 

2 Ibid., 1894, xii., 505. 



ATROPHIA PILORUM PROPRIA. 105 

or more or less complete suspension of its functions. It is 
a symptom rather than a disease. It may be local or gen- 
eral; temporary or permanent; symptomatic, as in fevers 
and diabetes; congenital, as in xeroderma; or neurotic. 
Some people never sweat perceptibly. In certain skin 
diseases, such as psoriasis, scleroderma, squamous eczema, 
and ichthyosis, the affected areas do not sweat. Its treat- 
ment is tonic by exercise and bathing. In symptomatic 
cases we must strive to remove the underlying cause. For 
congenital cases we can do nothing. 

Anonychia means congenital absence of the nail. 

Anthrax. See Carbuncle and Pustula maligna. 

Aplasie Moniliforme. See Trichorrhexis nodosa. 

Area Celsi. See Alopecia areata. 

Argyria is the blue or black discoloration of the skin 
and mucous membranes due to the deposition of particles 
of silver in the rete, sweat glands, and about the hair fol- 
licles, where it turns black by exposure to the sunlight. 
It used to be seen more often when silver salts were ad- 
ministered in the treatment of epilepsy than it is now. It 
occurs also in workers in metallic silver, minute particles 
of the metal becoming fixed in the tissues. It is a per- 
manent staining. 

Arthritide Pseudo-exanthematique. See Pityriasis rosea. 

Atheroma. See Sebaceous cyst. 

Atrichia. See Alopecia adnata. 

Atrophia Pilorum Propria. Atrophy of the hair exists 
under two forms, namely, Fragilitas crinium and Trichor- 
rhexis nodosa. In both forms the hair shaft is easily 
friable and splits or breaks of itself or by the slightest 
traction. 

Fragilitas Crinium. This disease has been called scis- 
sura pilorum, and has for its distinguishing feature split- 
ting of the hair. The cleft is usually at the free ex- 
tremity, and at times runs some distance up the shaft. 



106 DISEASES OF THE SKIN. 

The split hairs are either scattered here and there through 
the otherwise normal hair, or all the hairs of the part are 
split. The disease occurs most often upon the hair of the 
seal}), the beard being the place next most frequently affec- 
ted. It is a common occurrence in the long hair of women. 
The shaft may be split into two or more fibrillar, and these 
spread out from each other simply or curve up upon 
themselves. The cleft may also occur in the middle of 
the shaft or at its exit from the follicle, and in the latter 
case the shaft will be split throughout its entire length, 
the segments either separating or holding together. Duhr- 
ing 1 has reported a ca*e occurring in the beard in which 
the hair began to split within the bulb. Besides the split- 
ting, the hair may show no other abnormality, but it is 
generally more dry and brittle than normal, and may be 
irregular and uneven in its contour. The bulb of the hair 
may be normal or atrophied. 

Etiology. The cause of the idiopathic fragilitas crin- 
ium is yet undetermined. The disease is, without doubt, 
due to some interference with the nutrition of the hair, 
probably a yet undetermined tropho-neurosis. It is often 
seen in connection with a seborrheal dermatitis of the 
scalp. 

Treatment. When occurring only at the free end of 
long hairs they should be cut above the cleft. In all 
cases the scalp should be kept in good condition, as directed 
under Alopecia prematura. If the disease occur in the 
beard, shaving would at least remove the deformity and 
possibly cure the disease. 

Trichorrhexis Nodosa. Synonyms: Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

Symptoms. The disease most often affects the hair of 
the beard and moustache, and here it reaches its highest 
development. It is found also in the hairs of the pubic 
region and in the scalp hair. Raymond 2 says that he has 
found it on the labia majora in 40 per cent, of all women 
he has examined, and specially in fat women with inter- 
trigo. He has found it also on scrotal hairs. It consists 

1 Araer. Jonrn. Med. Sci., July, 1878, p. 88. 
2 Ann. de derm, et de syph., 1891, ii., p. 568. 



ATROPHIA PILOBUM PROPRIA. 



107 



Fig. 12. 



of one or more whitish or grayish, shiny, transparent nod- 
ular swellings occurring along the shaft of the hair. In 
people with red hair the color may be black. The num- 
ber of nodes that may be present is from one to five, and 
their size will vary with the diameter of the hair. The 
nodes, according to S. Kohn, 1 occur usu- 
ally in the upper third of the hair. These 
nodes give to the hair an appearance not 
unlike that produced by the presence of 
the nits of pediculi. The hair is exceed- 
ingly brittle and fractures upon slight 
traction or spontaneously, the fracture 
taking place through a node and the hair 
fibers separating like the hairs of a brush. 
When many hairs in the beard are thus 
broken, their frayed-out ends make the 
beard look as if it were singed. Some- 
times the hair fibers splinter about the 
node, but the two ends do not separate, 
and this gives an appearance like as if 
two small paint brushes were pushed 
together. Sometimes the hair presents 
an irregular contour and looks as if 
frayed along its entire length. While 
the fracture is usually transverse, if there 
should be an excessive amount of medulla 
present in the node it may be longi- 
tudinal. The hairs themselves are usu- 
ally firmly fixed in the follicles. 

Etiology. The cause of the disease 
is probably a micro-organism, as micro- 
organisms have been found in relation to 
the disease by Hodara, Essen, and others. 
E. Spiegler 2 has succeeded in cultivating a bacillus and in 
reproducing the disease by inoculation with its culture. An- 
derson 3 has reported a case of hereditary trichorrhexis nodosa, 
the disease in his patient being congenital or nearly so. 

1 Vierteljahr. f. Derm. u. Syph., 1881, viii., 581. 

2 Arch. f. Derroat. n. Syph., 1897, xli., 67. 

3 Lancet, 1883, ii., 140. 



Trichorrhexis nodosa 
(Michelson.) 



108 DISEASES OF THE SKIN. 

By some it is regarded as purely mechanical, due to the 
patient's habit of handling the beard. 

Pathology. The microscopical examination of the 
affected hairs shows that in the early stage of development 
of the disease there are simply a spindle-formed thickening 
in the continuity of the shaft of the hair and a swelling 
of the medulla, while the cuticle is still intact. Later the 
cuticle becomes cleft, and the cleavage extends on all sides 
of the node till the brush-like appearance is produced by 
spreading of the separate fibers. At the same time with 
the cleaving of the cuticle the medulla undergoes degenera- 
tive changes. There is either no marked change in the ap- 
pearance of the hair-root or it is slightly atrophied. Air- 
globules are only very occasionally found in or about the 
nodes. Spieglerhas found his bacillus in the hair beneath 
the epidermis and in the root-sheath. 

Treatment. The treatment of the disease is very un- 
satisfactory. Continued shaving probably offers the best 
hopes. All sorts of applications have been made to the 
affected parts, generally of a stimulating character, par- 
ticularly various forms of mercurials, but without curative 
effect. Gamberini, in his work on the hair, recommends 
either bathing the part with a lotion composed as follows : 

R Potass, subcarb., giij ; 81 

Alcohol. diL, adgv; ad 100[ M. 

or inunctions of tannic acid or oil of cade. 
Schwimmer advises that an ointment of 

R Zinci oxid., gr. vij ; 1 5 

Sulphur, loti, gr. xv ; 3, 

Ung. simp., ^ijss; 30| M. 

be rubbed in in the morning and evening. 

Besnier finds it useful to pluck the diseased hairs and 
to apply to the newly formed hairs tincture of cantharides, 
pure or diluted. Sabouraud advises using daily 
R 



M. 



Hydrarg. bichlor., 


gr. iv ; 


120 


Ac. tartaric., 


gr. viij ; 


40 


FJesorcin., 


gr. xv-xxx ; 


1-2 


Alcohol., 






AZther., 


aa 5Jss ; 


aa 50 : 



A TROPHODERMA. 1 09 

A two per cent, solution or ointment of pyrogallol or a 
three per cent, carbolic acid ointment has been advised by 
others. 

Allied to trichorrhexis nodosa we have Monilethrix, 
or ringed hairs, in which the hair shaft is marked by 
alternate swellings and constrictions, the latter being color- 
less. The hairs are liable to fracture through the con- 
stricted portion, in this way differing from trichorrhexis 
nodosa. The disease has been met with on the legs. It 
is probably due to a tropho-neurosis. It begins in the hair 
follicle. 

Atrophia Unguium. Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as 
lichen ruber acuminatus, pityriasis rubra, psoriasis, and 
syphilis ; or it may be caused by the invasion of the nail- 
bed by parasites, as in favus and ringworm. It may also 
occur like defluvium capillorum as a sequence to some 
grave acute illness, such as typhoid fever or scarlatina, or 
some cachexia, such as diabetes. The nails may be con- 
genitally absent or deficient, or become so without ap- 
parent cause. Injuries and certain chemicals will cause 
the nails to atrophy and fall. Atrophy is shown by white 
spots in the nails, by loss of lustre, by . transverse white 
lines, by longitudinal or transverse furrows, by a worm- 
eaten appearance, or by a general thinning and breaking 
away of the nail-plate. 

Treatment. The treatment is most unsatisfactory. 
If the cause can be discovered and removed, the nails will 
recover. In many cases all we can do is to protect the 
nail by rubber cots or by the use of wax or other pro- 
tective. Ointments of lead, zinc, or mercury may be 
rubbed in. The persistent use of sulphur ointment, com- 
bined with the administration of nerve tonics, will prove 
beneficial in those cases apparently dependent upon nerve 
disturbance. 

Atrophoderma, or Atrophia Cutis. Atrophy of the skin 
may be quantitative or qualitative ; idiopathic or sympto- 



110 



DISEASES OF THE SKIN. 



matic ; diffused or circumscribed. Crocker l gives this 
useful table : 



Atrophoderma 

Idiopathicum. 



Atrophoderma 
Symptomaticum. 



Difi'usuin 



Juvenili 
Senilis 



Circumscriptum 

(strise et macule) 

| Neuriticum 

(glossy skin) 



Morborum cutis. 



J Pigmentosum. 
\ Albidum. 
I Quantitativum. 
\ Qualitativum. 

f Traumaticum, 

\ Non-traumaticum. 

f Traumaticum. 
\ Non-traumaticum. 
f Scleroderma. 
I Seborrhcea. 
■{ Lupus. 

Syphilis. 
I Favus, etc. 



The symptomatic atrophies will be spoken of under 
their proper headings. The other forms of atrophy will 
be considered here. 

Atrophoderma Pigmentosum. Synonyms : Xeroderma 
pigmentosum (Kaposi) ; Angioma pigmentosum et atro- 
phicum (Taylor); Dermatosis Kaposi (Vidal) ; Liodermia 
essentialis cum melanosi et telangiectasia (Neisser) ; Mel- 
anosis lenticularis progressiva (Pick); Lentigo maligna 
(Piffard) ; Epitheliomatose pigmentaire (Besnier). This 
is a very rare disease of the skin, first described by Kaposi 
in 1870 under the name of xeroderma, to which he subse- 
quently added the adjective pigmentosum. It is a con- 
genital disease ; almost all cases begin before the second 
year of life. 

Symptoms. It affects the parts most exposed to the 
air ; the face, neck, chest, and back down to the level of 
the clavicles, or even the third rib, the backs of the 
hands, forearms, and upper arms. The hands, face, and 
neck are most markedly diseased, while a few cases have 
occurred upon the legs and back of the feet. It begins 
with erythematous patches, like those produced by sun- 
burn. After a time brown or black freckle-like spots 
form upon the erythematous ones. They are from pin- 
head to bean size and round or irregularly shaped. Small 
1 Diseases of the Skin. Lond. and Phila.. 1888. 



ATROPHODERMA PIGMENTOSUM. 



Ill 



red spots appear among the pigmented lesions, which 
Taylor thinks are their forerunners. The pigmented 
spots in time give place to white atrophic ones, and the 
skin becomes too small for the underlying parts, so that 
it appears drawn and in some places bound down. A 
fully developed case presents a vast number of lentig- 
inous spots interspersed with white atrophic spots and 

Fig. 13. 




Atrophoderma pigmentosum. (After ( 



stellate and striated telangiectases. After a time, on ac- 
count of the atrophy of the skin, we find ectropion, 
thinned alse nasi, and contracted nasal and oral orifices. 
There may be white atrophic spots on the mucous mem- 
brane of the lips. Conjunctivitis generally supervenes 
upon the ectropion, and discharge from the eyes sets up 
ulcerations which in their turn give rise to other ulcer- 
ations. Warty growths at last appear, and these are prone 
to take on malignant action and be converted into epithe- 



112 DISEASES OF THE SKIN. 

liomas, and the patient dies at an early age from maras- 
mus. At first, however, there is no disturbance of the 
health. 

Etiology. The etiology of the disease is obscure. It 
is supposed by some to have its starting point in irritation 
of the skin by the sun or other irritant. Many of the 
cases begin in the summer. It is supposed by others to 
be a tropho-neurosis. It is found in both sexes, but is 
peculiar in affecting several members of the same family 
and of the same sex, and in occurring in the first or second 
year of life. It is not hereditary. In a few of the cases 
there was a history of cancer in the family. 

Diagnosis. The disease is to be differentiated from 
scleroderma by the peculiarity of its being limited to ex- 
posed parts, by lacking stony hardness, by occurring early 
in life, and by the general picture of pigmented and atro- 
phic spots and telangiectases being intermingled. It dif- 
fers from urticaria j/igmentosa in not itching, in not occur- 
ring upon the trunk, in the absence of wheals, and in the 
presence of telangiectases and warty or epitheliomatous 
growths. 

Treatment. Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as possible, 
and the warty growths and epitheliomatous nodules de- 
stroyed at an early date so as to prevent the development 
of epitheliomatous or carcinomatous ulcers. A saturated 
solution of boric acid will do much for the eyes; the ulcers 
may be treated with iodoform or aristol powder or a dilute 
ammoniate of mercury ointment ; while the warty growths 
should be scraped off with a curette. 

Prognosis. The disease is fatal, death from marasmus 
taking place in from ten to twenty years. 

Atrophoderma Albidum is the name used by Crocker for 
a second form of the xeroderma pigmentosum of Kaposi, 
which is described by the latter as beginning in childhood, 
affecting most frequently the lower extremities and less 
often the forearms and hands, and characterized by thin- 
ness of the skin, which in some places is stretched and 



ATROPHODERMA IDIOPATHICA DIFFUSA. 113 

cannot readily be taken up into folds. The color of the 
skin is pale and white, with a delicate rosy shimmer in 
places, and here and there its epidermis peels off in asbes- 
tos-like lamellae. The treatment is simply protective. 

Atrophoderma Idiopathica Diffusa. Diffused idiopathic 
atrophy of the skin is a very rare affection. It may be 
congenital or acquired, general or partial. The subcu- 
taneous tissue disappears, so that the skin lies close to the 
underlying parts. It is thin, pale, stretched or wrinkled, 
easily movable over underlying parts, and allows the blood 
vessels to show through. In some cases thick scaly plates 
form, while in others these are wanting and there is only 
slight scaling. The elasticity of the skin is lost, so that 
if it is pinched up into folds these slowly flatten out. In 
some cases the skin seems too small for the body, which, 
on the face, gives rise to ectropion and other deformities. 
The sensibility of the skin may not be diminished. The 
patients are susceptible to cold. Ulcers are prone to form 
upon slight injuries. The hair is destroyed. The disease 
is probably a tropho-neurosis. One case was ascribed to 
exposure to cold. 1 

Hardaway 2 reported two cases occurring in a brother 
and sister; and Ohmann-Dumesnil 3 has met with a case 
of atrophy of the skin and muscles of the right arm appar- 
ently following an injury to the radial nerve by means of 
a burn on the hand. 

One variety of diffused idiopathic atrophy of the skin is 
that called hemiatrophia facialis progressiva, in which only 
one-half of the face is affected, and the skin becomes 
thinned and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy shin 
of Paget, Weir Mitchell, and others. It commonly affects 
the fingers, less often the extremities, and follows upon dis- 
ease or injury of nerves. It occurs also in scleroderma. 
The fingers become dry, red, or mottled, look glazed or as 
if varnished, and are shrunken. The natural lines of the 

1 Pospelow; Ann. de derm, et de syph., 1886, vii., 505. 

2 Trans. Amer. Dermat. Assoc, 1884. 

3 Alienist and Neurologist, July, 1890, 



114 DISEASES OF THE SKIN. 

skin disappear and the nails fall off. If parts covered 
with hair are affected, the hair falls. Its tendency is to 
spontaneous recovery. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes also are present, as a rule. It may 
be partial or general. The skin looks wrinkled ; it is 
thrown into folds, is dry and sometimes scaly, and is often 
of darker color than normal. By pinching up the skin the 
thinness of it is readily appreciated. With the atrophy of 
the skin there are likewise loss of the subcutaneous fat, pru- 
ritus, and verruca senilis. Treatment is out of the question. 

Atrophoderma Striatum et Maculatum. By this is meant 
circumscribed atrophic streaks or spots. They may be 
idiopathic or symptomatic. The idiopathic form is far 
more rare than the symptomatic form. 

Symptoms. The idiopathic streaks are met with most 
often about the thighs, buttocks, and lower anterior part 
of the abdomen. They are one or two lines wide, slightly 
curved, and from one to several inches long. There are 
usually several present, and then they are arranged parallel 
to one another and run in an oblique direction. The 
macules are isolated, from pinhead to finger-nail size or 
larger, occur most frequently on the extremities and lower 
part of the trunk, but may occur as high up as the neck, 
and are less common than the streaks. Both forms of 
lesion are depressed below the surface of the skin, and are of 
a pearly or bluish-white color and have a glistening, scar- 
like appearance. They are not primary atrophies, but suc- 
ceed to an erythematous hypertrophic lesion, in this greatly 
resembling morphoea. They give rise to no inconvenience, 
and are accidentally discovered. They usually are per- 
manent, though they may become less pronounced in time. 

Etiology. The etiology is obscure. By many it is re- 
garded as a tropho-neurosis. Shephard 1 and Duckworth 2 
have reported cases of atrophic spots and lines following 
fevers. 

1 Trans. Araer. Dermat. Assoc, 1890, p. 23. 

2 Brit. Journ. Dermat., 1893, v., p. 357. 



BISKRA BOUTON. 115 

Symptomatic lines and macules are very common, and are 
caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissues of the 
skin. If the fibres are ruptured, the strise will be most 
pronounced, and there will be little left of the skin but the 
epidermis and a thin fibrous membrane. 1 This form of 
atrophy of the skin is seen upon the abdomen of pregnant 
women (lineaz albicantes) and on the breasts of nursing 
women. In fact, anything that greatly distends the skin 
may give rise to them, such as abdominal ascites, obesity, 
ovarian or other tumors. 

Treatment. The treatment of these cases is purely 
expectant. Both the idiopathic and the symptomatic 
atrophies may grow less pronounced in time. 

Aussatz. See Leprosy. 

Autographism. See Urticaria factitia. 

Baelzer's Disease of the lip is a chronic affection of the 
mucous glands of the lip marked by an indolent swelling 
and infiltration of the periglandular tissue, and a slow 
ulceration from above downward. It ceases only with the 
destruction of the affected gland. The neighboring lym- 
phatic glands are not implicated. A superficial catarrhal 
inflammation of the mucous membrane of the lips fre- 
quently accompanies the process. There is no general 
systemic disturbance. It has no relation either to syphilis, 
tuberculosis, or cancer. It is regarded as a local infection. 
It is readily cured by the application of tincture of iodine, 
which at first is used every other day, and later every day. 

Baker's Itch. See Eczema. 

Baldness. See Alopecia. 

Barbadoes Leg. See Elephantiasis. 

Barber's Itch. See Trichophytosis barbae. 

Birth-mark. See Nsevus. 

Biskra Bouton, or Biskrabeule. See Aleppo boil. 

1 Taylor, E. W. : New York Med. Journ.,1886, xliii., p. 1. 



116 DISEASES OF THE SKIN. 

Blackheads. See Comedo. 
Blasenausschlag. See Pemphigus. 
Blutfleckenkrankheit. See Purpura. 
Blutgeschwiir, or Blutschwar. See Furunculus. 
Blutschweiss. See Hsematidrosis. 
Boil. See Furunculus. 
Bouton d'Amboine. See Yaws. 
Brandrose is a phlegmonous erysipelas. 
Bricklayer's Itch. See Eczema. 

Bromidrosis. Synonym : Osmidrosis. This word means 
stinking sweat, which, though not elegant, is expressive. 
It most often affects the feet, and then is associated with 
hyperidrosis. It may be general, as in the negro race. 
The odor is not necessarily repulsive, a few cases having 
been reported in which it was that of violets. The axillae 
are, next to the feet, the most common site of the trouble. 
The odors of different fevers and cachexia? are usually 
classed under this heading, though they do not properly 
belong here. 

Strictly speaking, bromidrosis should include only those 
rare cases in which the sweat, when secreted, has a dis- 
tinctive odor. Usually the odor in bromidrosis is not in 
the sweat, but in the products of decomposition, the fatty 
acids and the like. When the feet are the parts affected 
they will be found to be of a pinkish color about the soles 
and between the toes, or the skin will look sodden and 
grayish. When the hyperidrosis is well marked, and it 
commonly is, the feet may be so tender as to interfere with 
locomotion. The stench from a pronounced case is such 
that it is almost impossible to stay near the subject of the 
disease. 

Etiology. The cause of general bromidrosis is either 
inherent in the race or unknown. Most of the cases, apart 
from the racial ones, have been in hysterical subjects. In 
the usual form of the disease it is due to decomposition of 



BULPISS. 117 

the sweat in the stockings, shoes, or clothing of the indi- 
vidual. When the part is uncovered and kept clean there 
is no odor. Thin has described a parasite, that he has 
named bacterium foetidum, as the cause of the disease. It 
has been supposed that this bacterium can live only in an 
alkaline medium. The sweat is acid, and, therefore, on 
most feet it does not grow, but when hyperidrosis macer- 
ates the epidermis and allows of the escape of serum the 
acidity of the sweat is neutralized and the bacterium flour- 
ishes. 

Treatment. The treatment of the general cases is of 
no effect. In the local cases the hyperidrosis is to be over- 
come, as will be described in its proper place. The special 
treatment directed to the cure of the odor of the feet is to 
wash them with soap and water two or three times a day, 
to put on a clean pair of stockings every morning, to ven- 
tilate the shoes thoroughly, and to dust the feet, between 
the toes, the stockings, and the inside of the shoes with 
finely powdered boric acid. Thin recommends the wearing 
of cork inside soles, which are to be soaked in a saturated 
solution of boric acid and dried before using. Another 
useful powder is : 

R Ac. salicylici, ^jss-iij ; 5-10 

Pulv. alum, exsic. vel. } , ~... ■■ inA 

,3 i i j.. V ad 5ni : ad 100 

Pulv. lycopodn, j ° J ' 

to be applied in the same way, twice a day. This will 
cause the skin to exfoliate, when the treatment may be 
stopped. 

W. Osier 1 reports one case of general bromidrosis cured 
by the administration of alkalies. 

Bucnemia Tropica. See Elephantiasis. 

Bulpiss' 2 is a disease that occurs in Nicaragua, affecting 
every tribe, both sexes, and all ages, though rare in early 
infancy. It begins on the feet and hands, and spreads 
gradually, or upon the knees, or abdomen, or neck and face. 
Two kinds are described. In the white bulpiss there are 

1 Montreal Med. Jonrn., 1896-7, xxv., 890. 

2 O. Lerch : New Orleans Med. and Surg. Journ., 1894-5, xxii., 793. 



118 DISEASES OF THE SKIN. 

crops of minute reddish papules, which on disappearing 
leave discolored spots. After a time the pigmentation 
fades away and leaves a dirty white, round or oval patch, 
with slightly elevated and partly discolored broad margins. 
In black bulpiss the patches are grayish black, and the skin 
is dry and shrivelled. Both kinds itch at night. It is 
contagious and probably parasitic. It resembles if it is 
not identical with carate. 

Bunion. According to P. Syms, 1 a bunion is always sec- 
ondary to an outward displacement of the first phalanx of 
the great toe due to ill-fitting shoes. As a result we have 
a periostitis with hyperplasia, and finally exostosis of the 
metatarsal bones. The pressure between the exostosis and 
the shoe gives rise to an inflamed bursa, the bunion. Sur- 
gical interference and properly constructed shoes are the 
only remedies. 

Cacotrophia Folliculorum. See Keratosis pilaris. 

Calculi, Cutaneous. See Milium. 

Callositas. Synonyms : Callosity ; Callus ; Tylosis ; 
Tyloma ; Keratoma ; (Fr.) Durillon. This is familiar to 
all as the callous skin of the hands met with in oarsmen, 
blacksmiths, and in those who follow other manual occu- 
pations, and is a hypertrophy of the epidermis consequent 
upon intermittent pressure of the skin against the under- 
lying bone. Constant pressure will cause atrophy. The 
same thickening of the skin is found upon the soles also, 
due to going barefoot or wearing improperly fitting shoes. 
In fact, it may develop anywhere under proper conditions. 

Treatment. No treatment is necessary for the ac- 
quired forms. Cessation from using the hands will be 
followed in course of time by the disappearance of the 
callus. To hasten its removal we may use maceration 
with rubber cloth continuously applied to the part, or a 
plaster of salicylic acid, or a solution of salicylic acid ten 
to twenty per cent, in ether or collodion. The action of 
these remedies will be aided by previously paring down 
the part with a sharp knife. 

1 New York Med. Journ., 1897, lxvi., 448. 



CANITIES. 119 

Callus. See Callositas. 

Calvez ^| 

Calvezza V See Alopecia. 

Calvities j 

Cancer. See Carcinoma and Epithelioma. 

Cancroide. See Epithelioma. 

Canities. Synonyms : Trichonosis cana ; Trichonosis 
discolor ; Poliothrix ; Poliosis ; Trichonosis poliosis ; Spi- 
losis poliosis ; Poliotes ; Grayness of the hair ; Whiteness 
of the hair ; Blanching of the hair ; Atrophy of the hair 
pigment. 

Grayness or whiteness of the hair may be congenital or 
acquired; the latter is by far the most common. The 
whiteness is either partial or complete. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously among the normal-colored 
mass. When the whiteness is general we have albinism, 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age, it may be con- 
sidered as premature ; and when after this age as senile. 
Premature canities is by no means uncommon, many per- 
sons becoming gray between the twentieth and twenty- 
fifth year. The hair which first whitens is, as a rule, 
that of the temples ; then follows, with more or less 
rapidity, that of the vertex and whole head. Sometimes 
the beard first turns gray, but usually it changes color after 
the hair of the scalp. The last hair to become gray is 
that of the axillse and pubis. When the graying is due 
to some passing cause, as anxiety or some diseased state, 
the process may cease completely upon removal of the 
cause. Usually the whiteness is permanent. As a rule, 
there is no change in the color of the scalp, though in 
some cases gray tufts are found upon pale-yellow patches 



120 DISEASES OF THE SKIN. 

of scalp. As in alopecia, so in canities, men are more 
frequently affected than women. 

The hair in canities is usually unchanged except in 
color, but it may be drier and stiffer than normal. Cani- 
ties may exist for years without alopecia. 

The hair turns gray first at its root. The color at first 
is gray on account of the mixture of the normal color with 
the whiteness due to the absence of pigment. Gradually, 
the white parts gain the ascendant, and the whole hair is 
blanched, becoming finally of a yellowish or snowy white- 
ness. The darker the hair is originally the more it is 
prone to turn gray. 

Sudden change of color of the hair from its normal hue 
to perfect white has been too well authenticated to allow 
of a doubt as to its occurrence, though it has been denied 
by good authorities, who have questioned the correctness 
of the observations reported. 

Ringed hair is an anomalous variety of blanching of the 
hair in which the affected hairs are marked by alternate 
rings, one being that of the normal color, and the next 
white. The occurrence of this disease is very rare and 
but few cases have been reported. 

The hair has been known to lose its color under varying 
circumstances. Very commonly the first hair that comes 
in after alopecia areata is white. Wallenberg 1 reports a 
case in which, after an attack of scarlatina, the patient's 
brown hair was entirely lost and replaced by a growth of 
white hair. Prolonged residence in a cold climate, with 
much exposure, will cause the hair to turn gray. Some- 
times the hair will change its color with the season, becom- 
ing gray in winter and darker in summer. On the other 
hand, Cottle 2 gives prolonged residence in hot climates, 
with much exposure, as a cause of canities. Albinoes, 
we know, are most frequent in the negro races, which 
inhabit the hot countries. 

Etiology and Pathology. Senile canities and many 
cases of the premature form are due to an obscure change 
in the nutrition of the hair papillae which interferes with 

1 Vierteljahr. f. Derm. u. Syph., 1876, iii., 63. 

2 The Hair in Health and Disease. London, 1877. 



CARATA 121 

the production of pigment. Only this function of the 
papillae seems to be interfered with, as the hair-forming 
function is in full activity, judging from the fact that the 
hair in many cases is in full vigor. In cases of sudden 
blanching of the hair the change of color is dependent 
upon the formation of air bubbles between the hair cells 
of the cortical substance, the presence of the air rendering 
the cortical substance opaque, so that the color of the pig- 
ment is obscured. There are various agents which act as 
active or exciting causes of canities. Age is one of the 
most prominent of these. Heredity exerts marked influ- 
ence upon the blanching of the hair, most of the members 
of certain families turning gray at an early period of life. 
Neuralgia of the fifth nerve, dyspepsia of various forms, 
sudden fear or nervous shock (producing sudden blanching 
of the hair), profuse and frequent hemorrhage, excesses 
of all kinds, chronic debilitating diseases (as syphilis, ma- 
laria, and phthisis), local diseases or injuries to the scalp, 
as wounds, favus, repeated epilation, prolonged shaving, 
and the like, have been given by various writers as causes 
of canities. Schwimmer regards it as being principally a 
tropho-neurosis, and finds in the occurrence of grayness 
in the course of neuralgia a strong argument for his 
theory. 

Treatment. We cannot restore the color to gray 
hairs. In some cases of canities occurring in the course 
of neuralgias, if we can cure the neuralgia, the color will 
gradually return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promoter of pigmentation, as they have seen numerous 
instances of its use in alopecia areata followed by growth 
of hyper-pigmented hair. 

All that can be done for canities is to restore artificially 
the color by means of hair dyes, and their use is to be 
deprecated. Happily the custom of dyeing the hair is 
falling out of fashion. 

Carats. This is an endemic, parasitic disease of the 
skin met with in the United States of Colombia and in 
other South American countries. It has an incubation 



122 DISEASES OF THE SKIN. 

stage of about one month. It begins as an erythematous 
macular eruption, sometimes preceded by itching. 

The macules cover themselves with fine scales ; their 
centers gradually become violaceous, red, or blue. After 
from two to five years the macules become violet, black, 
yellow, or white in color. Upon the same subject may be 
found variously colored patches. After some years the 
greater part of the surface of the body may be aifected, 
and the mucous membranes may be invaded. Itching is 
pronounced. The palms and soles become thickened. The 
flexures of the joints may be ulcerated and painful, and 
covered with small corns. The hair may fall from the 
patches on the body. The duration of the disease is 
indefinite. 

It is due to a fungus that is found in the stagnant 
waters of gold mines and in the grains of certain cereals, 
and it is transmitted also by mosquito-bites. 

It differs from pinta in its slower development, less con- 
tagiousness, and in the characters of its fungus. 

The treatment consists in the use of such remedies as 
mercurial ointment, tincture of iodine, and chrysarobin. 

Carbuncle. Synonyms : Anthrax, 1 Carbunculus ; (Ger.) 
Brandschwar. 

A phlegmonous inflammation of the skin and subcu- 
taneous tissue, attended with sloughing. 

Symptoms. The disease begins as an innocent-looking 
papule, which, however, is far more painful, both subjec- 
tively and objectively, than an ordinary papule would be. 
Within twenty-four hours it becomes larger, more pain- 
ful, slightly raised and reddened, and is generally accom- 
panied by a good deal of constitutional disturbance, such 
as chills, fever, and nervous irritation. All the symptoms 
increase in severity, the inflammation extends laterally 
and vertically, the swelling becomes darker in color, the 
pain more intense, throbbing, and lancinating, and the 
constitutional disturbance may be so severe that the patient 
is compelled to go to bed. Within ten days, or perhaps 

1 Anthrax, a term that is often applied to carbuncle, should be used 
rather for malignant pustule or the local manifestation of splenic fever. 



CARBUNCLE. 123 

longer, the swelling has reached its height. It may be 
two or three inches or more in width, with a brawny base 
that is more or less sharply defined, of irregular shape, 
firm to the touch, and with a wide area of cedematous skin 
about it. Now it begins to soften, not like a boil with a 
central point, but by the formation of a number of pea- 
sized purulent points, through which sanious pus exudes, 
giving to the surface a cribriform appearance. Sloughing 
takes place through the openings, that gradually enlarge, 
so that at last there results an irregular, deep, excavated 
ulcer with firm, sharply cut, everted edges. In very bad 
cases the whole mass may fall out at once. The ulcer 
gradually fills up, heals, and leaves a scar. With the dis- 
charge of the slough the patient gradually recovers his 
health ; but in some cases, especially in persons already de- 
bilitated or in elderly people, the disease runs a fatal course, 
the patient dying of exhaustion or pyaemia, or the disease 
runs into a typhoid condition preceding death. Death 
may also result from acute sepsis, or from thrombosis or 
embolus, especially in carbuncles on the scalp. In some 
cases the resulting ulceration is very large, with a corre- 
sponding amount of general disturbance of the system. 
Dry gangrene may take place. 

The disease is rare in children, and most common in 
middle and old age. Men suffer more often than women. 
The most frequent locations of the disease are the upper 
dorsal region, back, buttocks, and forearms, though it may 
occur anywhere. It is usually a single lesion. The dura- 
tion of the whole process is six weeks or more. 

Etiology. The causes of the disease are very much 
the same as those of boils. While carbuncle is most apt 
to occur in those who are not in good health, it does occur 
at times in apparently robust subjects. Diabetics are fre- 
quent subjects ; gout and uraemia have been considered as 
predisposing causes. The frequent location of the disease 
about the shoulders and on the back of the neck suggests 
pressure as a determining cause. Micro-organisms are 
the exciting cause of the disease, the staphylococcus pyo- 
genes aureus being constantly found in the tissues of a 
carbuncle. 



124 DISEASES OF THE SKIN. 

Pathology. To Warren, 1 of Boston, we owe one of 
the most thorough studies of the pathology of carbuncle. 
He declares it to be a speading phlegmonous inflamma- 
tion of the subcutaneous cellular tissue. The inflamma- 
tory cells cluster in and about the columnse adiposa? and 
push out laterally from them, infiltrating the skin. They 
reach the surface by mounting up along the hair follicles 
and arrectores pilorum muscles. 

Diagnosis. Carbuncle differs from furuncle in being 
single ; in its brawny base ; in its greater painfulness and 
constitutional disturbance ; in its flatter shape and larger 
size, and especially in its opening at many points and pre- 
senting a cribriform surface rather than a central core and 
a crater-shaped opening. Its circumscribed shape, its lan- 
cinating pain, and its multiple sieve-like openings distin- 
guish it from diffuse phlegmonous inflammation of the skin. 
Anthrax becomes gangrenous earlier than carbuncle and its 
center sinks in instead of becoming elevated. 

Treatment. As the disease is an exhausting one the 
patient's strength is to be supported from the start and his 
nutrition kept up by a generous diet. Fresh air by good 
ventilation must be secured. If the pain is excessive, 
opium or morphine is indicated, especially to procure 
sleep. Iron is a valuable remedy all the way through, 
and antipyretics should be administered if the fever is 
high. Alcohol should be given if suppuration is free, 
especially if there are any signs of exhaustion. 

The best local treatment in mild cases is the use of car- 
bolic acid, and this gives such good results as to leave little 
to be desired. The crucial incision formerly practised is 
now considered by many modern authorities as harmful, 
though it certainly gives relief for the time by removing 
tension. In like manner the old-time method of poultic- 
ing is condemned, though it, too, contributes to the comfort 
of the sufferer. For ordinary carbuncles the most efficient 
treatment is to inject them at several points with a five or 
ten per cent, solution of carbolic acid in olive oil or glyc- 
erin, by means of an ordinary hypodermic syringe. When 
there are already sloughing points it is well to push into 
1 Boston Med. and Surg Journ., 1881, civ., 5. 



CARCINOMA. 125 

each of them a little absorbent cotton wound on the end 
of a wooden toothpick and dipped in carbolic acid either 
pure or in one to four solution. These procedures are 
painful for a moment. The mass must then be covered 
with lint soaked in a weak solution of carbolic acid. It is 
possible to abort some carbuncles by touching them with 
pure carbolic acid. E. O. Ashe 1 reports the cure of one 
case by the injection of antistreptococcic serum. Eade 2 
says that it is possible to abort cases in the papular stage 
by continuous soaking with a solution of a mild anti- 
septic, such as boric or salicylic acid. 

Canquoin's paste and a solution of chloride of zinc, 1 : 50, 
have been recommended for use in the same way as the 
carbolic acid. 

Extensive carbuncles are to be treated on surgical princi- 
ples by incision or erosion with a curette. The resulting raw 
surface, as well as that of ordinary carbuncles, is to be dressed 
antiseptically with iodoform, iodol, or aristol in powder. 

Carcinoma. Epithelioma is the form of cancer that 
most frequently is met with in the skin. It will be de- 
scribed under its proper heading. Carcinoma of the scir- 
rhous variety rarely attacks the skin, but when it does it 
may be primary or secondary. Most commonly it is sec- 
ondary to the same disease of the breast or internal organs. 
It may follow extirpation of the primary deposit, and then 
is prone to begin in the scar. Two varieties are described, 
namely : Carcinoma lenticulare and Carcinoma tuberosum. 

Carcinoma Lenticulare generally appears on the chest 
in the neighborhood of the breast and secondary to a 
mammary cancer or in the scar resulting from a previous 
operation for the removal of a cancer of the breast. It 
appears in the form of smooth, firm, glistening, dull, or 
brownish-red or pinkish nodules raised above the surface 
and discrete at first. In size the nodules vary from that 
of a pea to that of a bean. After a time the nodules run 
together and form a thick, indurated mass, which may in- 
volve so much of the chest as to interfere with breathing. 

i Brit. Med. Journ., 1898, ii., 1427. 
2 Lancet, May 19, 1888. 



126 DISEASES OF THE SKIN. 

This is the cancer en cuirassc of Velpeau. Now the 
neighboring lymphatic glands are involved and the arm of 
the same side becomes swollen and useless. In a short 
time the nodules and the mass break down and ulcerate, 
and the patient soon dies of exhaustion. 

Carcinoma Tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the 
skin and subcutaneous tissues. These are of a dull-red, 
violaceous or brownish-red color. They do not tend to 
run together, but they break down and ulcerate, and the 
patient dies just as in the lenticular variety. It usually 
appears in old people. 

In both forms there may or may not be lancinating pains, 
or there may be simply itching. In both, metastasis may 
take place. 

Carcinoma Melanodes is described by most authors as 
a third form of carcinoma, but Robinson, Crocker, and 
Brocq regard it as melanotic sarcoma. It is impossible to 
distinguish them clinically from sarcoma, which see. 

Diagnosis. The diagnosis of carcinoma is not difficult 
when one is aware that there is such a disease, and knows 
that in a given case there has been, or is, a carcinoma else- 
where. The mode of evolution of the lesions, the involve- 
ment of the lymphatic glands, and the lancinating pains, 
all point toward carcinoma as against a tubercular syphilide, 
lupus, or leprosy. 

Treatment. The treatment of carcinoma of the skin 
is the same as that of other forms, and is quite as unsatis- 
factory. 

Chair du poule. See Cutis anserina. 

Chalazodermia. See Dermatolysis. 

Chancre. See Syphilis, initial lesion of. 

Chap. Usually a mild form of eczema or dermatitis, 
attended with superficial cracking of the epidermis. It is 
generally due to exposure to cold and affects exposed parts, 
as the backs of the hands and the lips. Thorough drying 



CHLOASMA. 127 

of the hands after washing and keeping them covered from 
the air will prevent its occurrence on the hands. Rubbing 
into the skin cold cream from time to time during the day 
or at night, or the use of a drachm of glycerin in an ounce 
of rose-water, will prove curative. Avoiding wetting the 
lips, and making some greasy protecting application, such 
as camphor ice, will prevent the lips from being affected. 

Charbon. See Carbuncle. 

Cheilitis Glandularis Aposthematosa is a disease of the 
lips, usually the lower one. The lip becomes gradually 
swollen, firm, and rather hard to the touch, and its mobility 
is impaired. The mucous glands become swollen and can 
be felt as nodular masses. A turbid mucopurulent secre- 
tion is poured out at times, and the gland ducts are more 
or less dilated. No pain attends the disease, which is 
exceedingly obstinate to treatment. Black wash is recom- 
mended in its treatment, together with the occasional 
application of nitrate of silver. 

Cheiro-pompholyx. See Pompholyx. 

Chelis and Cheloide. See Keloid. 

Chilblain. See Dermatitis congelationis. 

Chloasma. Synonyms: (Fr.) Chloasme, Panne hepa- 
tique, Tache hepatique, Chaleur du foie, Masque ; (Ger.) 
Pigmentflecken, Leberflecken ; (Ital.) Macchie epatiche ; 
(Eng.) Liver spot, Moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 
formation of yellowish, brownish, or blackish patches of 
various sizes and shapes. 

Symptoms. In this disease the only alteration of the 
skin is in its color. The disease consists in a deposit of 
pigment in the rete mucosum, and occurs in the form of 
circumscribed or diffused patches of yellowish to black 
discoloration. When the color is black it is called mel- 
asma, or melanoderma. The size of the patches varies 
greatly from a small spot up to a general bronzing of the 
skin. 

The disease may be primary or secondary, idiopathic or 



128 DISEASES OF THE SKIN. 

symptomatic. The idiopathic forms are most often second- 
ary to some irritation. Thus it occurs with or in conse- 
quence of irritants applied to the skin, such as blisters or 
even sinapisms ; prolonged scratching on account of some 
pruriginous disease, such as prurigo, pruritus cutaneus, 
chronic urticaria, scabies or pediculosis; exposure to the 
sun's rays or high winds, or even to heat, as of the furnace 
in iron workers, and then on exposed parts. These all 
cause more or less hyperemia of the skin, and besides the 
deposit of the pigment there is more or less discoloration 
from the changes taking place in the extravasated blood. 
Allied to these causes and acting in the same way is the 
discoloration of the skin of the legs met with about old 
varicose ulcers and sometimes without the ulcers when 
there are marked varicosities. 

The symptomatic form may likewise be primary or sec- 
ondary. It is primary in that most common form of all 
that is known as Chloasma uterinum, or the mask, a form 
of hyperpigmentation of the skin of the face that occurs 
during pregnancy, or with uterine or ovarian irritation, and 
that is not met with after the menopause. It usually takes 
the shape of a diffused brownish, light or dark discolora- 
tion of the forehead alone, or also about the mouth and 
cheeks. Usually it extends only across the forehead and 
down the temples, and is either a continuous or interrupted 
patch with sharply defined borders. Sometimes it is mac- 
ular in character and occurs on the eyelids, lips, and chin. 
Under the same conditions there takes place a deepening 
of the color about the nipples and along the linea alba. 
The darkening of the color under the eyes of menstruating 
women is largely due to vascular congestion, and little, if 
at all, to chloasma. After a time in some women true 
chloasma does occur there. 

Primary pigmentation also occurs in certain cachexia?, 
such as Addison's disease, tubercular leprosy in Europeans, 
abdominal tuberculosis, cirrhosis of the liver, cancer of the 
stomach, malaria, diabetes, exophthalmic goitre, and multi- 
ple melanotic sarcoma. There is also an earthy look to 
the skin in secondary syphilis, as well as in congenital 
syphilis. Primary chloasma is also seen as the result of 



CHLOASMA. 129 

the ingestion of arsenic. Argyria is not a chloasma, strictly 
speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphiloderma and of lichen ruber planus ; these derma- 
toses disappearing to leave behind them, for a greater or 
less length of time, hyperpigmented spots. It may 
occur after other diseases of the skin, but is usually more 
fugitive. It is also seen in senile atrophy of the skin. 
There is hyperpigmentation about the patches of leuco- 
derma and in scleroderma. There is also a pigmentary 
syphilide met with upon the neck in women. 

Etiology. The cause of chloasma is undetermined in 
most cases. A late theory of the pigmentation following 
exposure to the sun is that it is due to the action of the 
chemical rays of the sun upon the constituents of the blood. 
We know also that in some cases of hyperpigmentation 
the color is due to changes taking place in the coloring 
matter of the extra vasated blood. That there is a relation 
between chloasma uterinum and the uterus we know, 
because the chloasma usually clears away either after par- 
turition, the cure of the uterine disorder, or the attainment 
of the menopause. 

Diagnosis. The diagnosis is usually easy. Discolora- 
tions caused by artificial means can be washed off. Chro- 
mophytosis is scaly and can be scraped off with the nail. 
Chromidrosis is very rare and can be washed off with 
chloroform or ether. 

Treatment. The treatment of chloasma is very un- 
satisfactory. In many of the symptomatic cases removal 
of the cause will be followed by disappearance of the color. 
Our first duty is to try to find the cause and, if possible, re- 
move it. While it is possible to remove the color, it is very 
prone to return. Glacial acetic acid touched on in spots 
will reduce the color and sometimes remove it. The same 
may be said of other acids, care being used not to cause too 
great destruction of the skin by the stronger ones. The 
bichloride of mercury in one to two per cent, solution may 
be used for the purpose, applied repeatedly or else kept on 
continuously for three or four hours. It is not always a 
safe procedure. Salicylic acid, ten to fifteen per cent, in 

9 



130 DISEASES OF THE SKIN. 

ointment, paste, or plaster, or in saturated solution in 
alcohol, may do well. Unna has recommended washing 
the part -with alcohol and applying over night a mercurial 
plaster made with the ammoniate of mercury. The next 
day this is to be removed and the following ointment is 
to be applied : 

R Bismuthi subnit., \ -- _• ----- 

Vaselini, ^vj ad 5jss ; 30J M. 

Brocq advises a mercurial plaster during the night, 
bathing morning and evening with a three or five per cent, 
solution of bichloride of mercury, and wearing during the 
day oxide of zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary dis- 
appearance of the pigmentation. In all cases in which 
there is an underlying cause attention must be given first 
to it. 

Prognosis. Many of the symptomatic pigmentations 
disappear when the patient recovers his health. It is not 
well to promise a certain disappearance of the patches, as 
some of them are permanent. 

Chondritis. See Scleroderma. 

Chromidrosis. Synonyms : Ephidrosis tincta ; Stearrhoea 
or Seborrhcea nigricans ; Pityriasis nigricans ; (Fr.) Cyan- 
opathie cutanee, Melastearrhee. 

This is a conditioD in which the sweat has an abnormal 
color. Usually it affects only limited regions, especially 
the lower eyelids. The color is most commonly blue or 
blue black. The subjects are most often hysterical women, 
and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be affected. 
Next in frequency the colored sweat forms on some other 
part of the face, but it may occur on any portion of the 
body. Besides the blue or black color, cases of yellow, 
green, brown, and even rose color have been reported. A 
few men have exhibited the phenomenon. Hoffmann 1 
reports a case of blue sweat of the scrotum of a man 
1 Wien. med. Wochenschr., 1873, xxiii., 291. 



CHROMWROSIS. 131 

seventy-two years old, and White 1 has met with a case of 
yellow sweat in a man twenty years old. R. W. Taylor 
saw one case of apparently blue sweat that occurred in a 
man taking iodide of potassium, and was due to a reaction 
between the starch of his shirt and the iodine contained in 
the sweat. Constipation and nervous derangements are 
often found in the cases. The chromidrosis has been noted 
to grow worse with increased constipation, and become 
better when that condition was removed; to be more pro- 
nounced at menstrual periods, and to break out suddenly 
under emotional excitement. The skin may present no 
appearance of change except the discoloration, or it may 
have an evident deposit upon it. In either case the color 
can be removed by wiping with a little oil, or scraped off 
partially with the finger-nail. 

Etiology. The cause of the disease is obscure. It 
has been thought to be due to the presence of colorless 
indican in the sweat, which becomes blue by oxidation. 
This accounts for a few cases at least. 

Diagnosis. The diagnosis is easy because the discolor- 
ation can be readily removed by an oiled cloth, while that 
of chromophytosis does not so readily come off, and that 
of chloasma does not yield at all. Moreover, neither of 
these last two conditions exhibits a blue color. 

Treatment. The disease requires stimulation in its 
treatment, and good results have been reported from the 
use of the following : 2 

R Ac. borici, gr. x ; 2 

Ac. salicylici, gr. xv ; 3 

Ungt. aquse rosae, ad 3J ; ad 100 

The red sweat that occurs in the axillae more especially, 
and elsewhere occasionally, is not a true chromidrosis, but 
is due to the growth of bacteria (micrococcus prodigiosus) 
upon the hair, as may readily be demonstrated under the 
microscope. The bacteria are sometimes present so abun- 
dantly as to encrust the hair. The same bacteria grown 
on culture-media are colorless, and it is supposed that the 

1 Journ. Cntan. and Ven. Dis., 1884, ii., 293. 

2 Van Harlingen : Handbook of Skin Diseases. 



132 DISEASES OF THE SKIN. 

action of the sweat upon them determines their color. At 
times not only are the hair and skin stained red, but also 
the underclothing is deeply dyed. 

A mild parasiticide ointment or oil with the use of soap 
and water, or a simple borax solution, will cure the dis- 
ease just as in chromidrosis. 

Green sweat has been seen in workers in copper. 
Yellow sweat has been found associated with bacteria and 
without them. 

Chromophytosis. 1 Synonyms : Pityriasis versicolor ; Tinea 
versicolor ; Chloasma ; Dermatomycosis microsporia ; 
Mycosis microsporia ; (Ger.) Kleien Flechte ; (Fr.) 
Pityriasis parasitaire. 

A vegetable parasitic disease, characterized by brown 
or cafe-au-lait colored, variously shaped and sized patches 
that occur chiefly upon the trunk. 

This disease is far more common than statistical tables 
show it to be, as it causes so little trouble that many peo- 
ple never think of applying for relief. It begins as a 
small yellowish point, which rapidly grows into a split- 
pea-sized lesion. Many new lesions appear and, these 
coalescing, patches form which may be so large as to 
occupy a great part of the chest or back. At first, when 
of small size, the patches are circular in shape, but as they 
grow larger they lose all definiteness of shape, though 
their edges are always sharply marked and sometimes 
raised. Annular patches sometimes form, and at other 
times there will be many more or less circular patches of 
sound skin in the midst of the diffused patch. The color 
is usually fawn or cafe-au-lait ; it may be brown or even 
black. The latter is reported only from tropical countries. 
In warm weather and in those who sweat profusely it is no 
uncommon thing to see the eruption present a pinkish hue, 
due to hyperemia of the skin. In negroes the patches are 
gray or chamois-skin-like in color. The edge of the patch 
may be somewhat raised, but the surface is not generally 

1 The name of chromophytosis was proposed for this disease by Dr. 
F, P. Foster, and has been well received in New York, as it quite ac- 
curately defines the disease and brings it in line with trichophytosis. 



CHROMOPHYTOSIS. 133 

above that of the skin. It presents various appearances. 
At times it is smooth and feels greasy ; at times it is dry 
and covered with fine branny scales ; while at times it looks 
rough, and, viewed in the proper light, it presents an 
appearance resembling that of ichthyosis of mild grade. 
These appearances are dependent upon the amount of 
sweating, which, if profuse, will remove the scales, espe- 
cially if the clothing rubs upon the skin. The greasy 
feel is imparted by the oily sebaceous matter, always 
marked in the region of the sternum, where chromophy- 
tosis most often is located. Whatever may be the appar- 
ent condition of the surface, scraping with the nail will 
remove a good part of the disease, showing that it is 
located in the upper layers of the epidermis. The patches 
are located chiefly upon the anterior surface of the chest 
and upon the abdomen. The back is also quite often 
affected, but not so markedly as the chest. In very ex- 
tensive cases the arms and legs may show the disease, and 
a few cases have been reported as occurring upon the face. 
C. W. Allen has pointed out that the disease is very often 
found concealed under the pubic hair. The rule is that 
the uncovered parts of the body are spared, and exceptions 
to this are very rare. The disease is not symmetrical. 
The number of patches varies from a few to hundreds. 

The only subjective symptom is itching, and this is often 
absent, and seldom so bad as to cause the patient to seek 
relief on that account. Patients desire to be treated on 
account of the deformity, not the discomfort, of the disease. 

Etiology. The cause of the disease is the lodgement 
and growth in the corneous layer of the skin of a vege- 
table parasite, the microsporon furfur. Like all other 
parasites of its class, this one is incapable of growth on 
every skin. It flourishes especially upon the skin of one 
who sweats freely. That consumptives were thought to 
be especially prone to the disease is due to the fact that 
their chests are exposed to the physician more often than 
are those of any other class of patients and the patches 
discovered. The disease is contagious, but its contagion is 
of low grade, and it is not common for it to take place 
even in such intimate relations as obtain between husband 



134 



DISEASES OF THE SKTK 



and wife. Adults from twenty to forty years of age are 
the most common subjects, though children may have the 
disease. According to Besnier and Doyon, the disease is 
never seen in very old people. It occurs in all countries, 
but most often in hot climates. It attacks all classes and 
conditions of men, and shows no particular discrimination 
in regard to sex. Its growth is interrupted by malarial 
paroxysms, and it peels off with the desquamation of scar- 
latina and measles. 

Pathology. The microsporon furfur is one of the 
most readily demonstrated of parasites. Place a few 
scales upon the slide, add a drop or two of liquor potassse, 
tease out the material a little, put on the cover-glass, and 
even with a low power the picture here represented will 

Fig. 14. 




Microsporon furfur. (After Kaposi.) 



be seen (Fig. 14). It consists of heaps of conidia, which 
are larger than those of ringworm, with any quantity of 
interlacing mycelia running between them. Free conidia 
are scattered about in the field. The fungus grows in the 
upper layers of the epidermis. It has been asserted that 



GHROMOPHYTOSIS. 135 

there were two kinds of fungus, one brown and the other 
pale red, each of which produces its own colored eruption. 
In 1896 T. Spietschka succeeded in making a pure cult- 
ure of the fungus, inoculating an individual with it, re- 
producing the disease and making pure cultures from it. 

Diagnosis. If one remembers the characteristic feat- 
ures of the disease, yellow or cafe-au-lait, scaly patches, 
that can be partly scraped away and are located chiefly 
upon the chest, little difficulty can arise in diagnosis. An 
appeal to the microscope will decide any doubtful ques- 
tion. Chloasma is not scaly, cannot be scraped off from 
the skin, and does not have spaces of normal colored skin 
in the midst of the patches. Leucoderma is an absence of 
pigment with a hyper-pigmentation about it that comes up 
to the white spot with a concave border and is not scaly. 
A fading erythematous syphilide occurs not in patches, but 
in isolated, round macules that are neither scaly nor itchy, 
that are usually most numerous over the abdomen and sides 
of the chest, and that are very often found as a dissem- 
inated eruption occurring upon the face as well as the trunk. 
Erythrasma is not so scaly and occurs only in or about the 
joints. Its parasite is much smaller than that of chromo- 
phytosis. 

Treatment. Anything that will cause the removal of 
the upper layers of the epidermis will cure chromophyto- 
sis when present only in slight degree. But it is best for 
safety to use a parasiticide. One of the pleasantest ways 
of curing the disease is to have the patient scrub his skin 
thoroughly with soap and water, preferably soft-soap, and 
then dab on, twice a day, a saturated solution of hyposul- 
phite of sodium. Sulphurous acid, pure or dilute, is a 
prompt remedy. Vleminckx's solution, one to three or 
six parts of water; bichloride of mercury, two or three 
grains to the ounce ; sulphur ointment rubbed in thor- 
oughly, and tincture of veratrum viride are efficacious. 
The danger of systemic poisoning by either the bichloride 
of mercury or the veratrum viride should deter us from 
using these remedies in extensive cases. Unna 1 recom- 
mends : 

1 Vierteljahr. f. Derm. u. Syph., 1880, vii., 166. 



136 DISEASES OF THE SKIN. 



R Tinct. rhei 



$1 aquosae, "| ,, 

Glycerini, j aa P- "■ M " 

Brocq gives the following : 

R Acid, salicylici, 2-3 parts. 

Sulphur, prsecip., 10-15 " 

Lanolini, 70 " 

Vaselini, 18 " M. 

Chrysarobin, naphtol, boric acid, and resorcin all are 
good. If the disease is very limited, it can be surely and 
speedily destroyed by painting the spot with tincture of 
iodine. 

There is only one point to be borne in mind in using 
any of these remedies, and that is, that they must be 
thoroughly used and continued for a time even after the 
last trace of the fungus seems to have been removed. If 
one spore is left behind, the disease is liable to return. 
Special care must be given to the cure of the disease in 
the pubic region. The underclothing must be boiled before 
it is used again. Relapses are common, as the patient's 
skin is susceptible to the lodgement of the fungus. 

Clastothrix. See Trichorrhexis nodosa. 

Clavus. Synonyms : (Fr.) Cor ; (Ger.) Leichdorn, 
Hiihnerauge; Corn. 

Symptoms. Corns are hyperplasias of the corneous 
layers of the skin due to pressure, and differing from cal- 
luses in having a central core that grows down toward 
the corium. They occur usually upon the toes, either over 
prominent joints, where they form hard corns, or between 
the toes, where, on account of being kept moist, they form 
soft corns. They are usually conical in shape and slightly 
projecting. Unless pared down they become painful by 
being pressed into the cutis. They are sometimes spon- 
taneously painful on the approach of wet weather on ac- 
count of their being hygroscopic. They may suppurate. 
They may occur upon the palm ; I have seen several 
cases in tennis players. The soles are sometimes affected 
with them, and then walking is rendered very painful. 



CLAVUS. 137 

Treatment. The best treatment for corns is to wear 
well-fitting boots and shoes, which must be neither too 
large nor too small. Pointed-toed shoes are especially apt 
to cause corns. The corn may be removed by the use of 
a salicylic acid plaster, or by Vigier's preparation, now 
sold in all the shops under the name of Hebra's Corn 
Remedy, which is composed of — 

K. 



Ac. salicylici, 


gr. xx ; 


1 


5 


Ex. cannabis indicxe, 


gr. x ; 




75 


Alcoholis, 


Til xx ; 


1 


5 


iEtheris, 


TTL lxxx ; 


5 




Collodion flex., 


ad 5SS ; 


15 





which is to be painted on three times a day for a week ; 
then the feet are to be soaked in hot water, and the corn 
picked out. Corns may also be cut out, but the operation 
is at times dangerous, especially in old people. Resorcin 
plaster of ten per cent, strength worn for some days will 
remove corns. Crocker recommends for soft corns careful 
daily ablution with soap and water, painting on them 
spirits of camphor at night, and wearing wool between the 
toes during the day. The ointment of the nitrate of mer- 
cury is commended for soft corns. But unless well-made 
shoes are worn the corns will be sure to return. Corns on 
the hands may be removed with salicylic acid or scraped 
out with the dermal curette. 

Clavus Syphiliticus. Under this title Lewin 1 describes 
certain lesions that he regards as being syphilitic. They 
are horny elevated growths that occur upon the hands and 
feet, and are sometimes surmounted by a delicate scaly 
crown, and sometimes covered with scales. They are 
from pinhead to lentil sized, circular, oval or oblong 
in shape ; flat or concave on top, but never convex, and 
appear as if wedged into the skin. At first they are pale 
red and soft, but later they become yellowish horn-color 
and hard. They are usually on the palms of the hands, 
but may be on the soles of the feet, as well as upon all 
surfaces of the fingers and toes. There is no pain caused 
1 Arch. f. Dermat. u. Syph., 1893, xxv., 3. 



138 DISEASES OF THE SKIN. 

by them. There may be some itching. The lesions are 
met with in both sexes, and occur early in the disease, 
and often symmetrically. 

Cnidosis. See Urticaria. 

Cold Sore. See Herpes facialis. 

Colloid Degeneration of the Skin. Synonyms: Colloid 
milium; (Ger.) Hyalom der Hant ; (Fr.) Hyalome cntane. 

Symptoms. This is a very rare disease of the skin 
that occurs most often on the upper part of the face in 
the form of disseminated or grouped, discrete, trans- 
parent, shining, rounded, lemon-yellow elevations of the 
skin. Though they look as though they were vesicles, 
they do not contain fluid, and when pricked give exit to 
only a small amount of gelatinous substance and a drop 
or two of blood. They are resistant to the touch. The 
course of the disease is slow. It is capable of spontane- 
ous disappearance by absorption or inflammation, leaving 
an ill-defined mark on the skin. It affects both sexes. 
The youngest patient so far reported was fifteen years old. 
It usually occurs in adult life. There are no subjective 
symptoms, and the general health is good. 

Diagnosis. It differs from xanthoma in its trans- 
parency and in the shining appearance and lemon-yellow 
color of the lesions. In xanthoma the lesions are soft and 
of a dull yellow. In hydrocystoma the lesions are more 
crystalline in appearance, and when pricked a drop of pure 
watery fluid escapes from them. In adenoma sebaceum 
the lesions are markedly vascular in places. 

Treatment consists in removing them by the curette 
or electrolysis. 

Comedo. Synonyms : Acne punctata, Acne follicularis ; 
(Fr.) Comedon, Acne punctuee, Tanne ; (Ger.) Mitesser, 
Hautwiirmer ; Grubs, Fleshworms, Blackheads. 

A comedo is a collection of inspissated sebaceous matter 
retained in a pilo-sebaceous gland, whose mouth is closed 
by a brown or black-topped plug of extraneous matter, 



COMEDO. 139 

and appears as a pin-point- to a pinhead-sized, slightly 
elevated, conical papule in the skin. 

Symptoms. Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wher- 
ever met with they present the characteristics indicated 
in the definition just given. They are unaccompanied by 
inflammatory symptoms. Just as soon as inflammation is 
caused by their presence they are converted into acne 
lesions — a change that they very commonly undergo. 
Usually they are scattered about irregularly ; sometimes 
they are grouped in certain regions. They are single 
lesions in the vast majority of cases, and being pressed 
between the thumb-nails they are readily expressed in the 
form either of an ovoid mass or more commonly as a fili- 
form or worm-like mass that may be a half-inch or more 
in length, and has a black head that obtains for them the 
popular names of " fleshworms " and " blackheads." Very 
exceptionally they are double, lateral pressure squeezing 
out a filiform mass with a black head at both ends, if such 
an expression is allowable. There may be but few, or 
there may be hundreds of them, so that the face looks as 
if sown with grains of gunpowder. The largest are found 
in the ears and on the back. They give rise to no sub- 
jective symptoms. Seborrhcea oleosa is frequently a 
marked complication. 

In children they are more apt to be grouped, and, ac- 
cording to Crocker, to appear on the forehead and occiput 
of boys, the temples in girls, and the cheeks in infants. 
The scalp, too, is in children the seat of the disease. Acne 
may follow them. 

Etiology. All that has been said as to the causes of 
acne applies with equal force to comedones, and need not 
be repeated here. We would only add that Unna l does 
not accept the commonly received doctrine that the black 
head and the clogging of the follicle are largely due to 
extraneous matter, but teaches that they are due to the 
corneous layer of the skin being abnormally firm and 
preventing the escape of the follicle contents by growing 
1 Virchow's Archiv, 1880, lxxxii., 175. 



140 



DISEASES OF THE SKIN. 



over its mouth. The black color he believes to be anal- 
ogous to the coloration of horns in cattle. He calls at- 
tention to the fact that comedones are more frequent in 
chlorotic girls than in coal-heavers. 

It is quite certain that man)' cases of comedones are 
directly due to dirt or other foreign matters stopping up 
the follicles. This is supposed to be especially the case 

Fig. 15 



Demodex folliculorum. (After Kuchenmeister.) 

in children. Colcott Fox 1 says that in them the come- 
dones are found most often in the spring-time and disap- 
pear in the winter. The youngest case in a child is one 
at twelve months. 2 

Pathology. The pathology of the affection is the 
same as that of acne without the evidence of inflammation. 
AYe find many varieties of micro-organisms in comedones. 
'Lancet. 1888, i., 665. 2 Crocker : Lancet, 1884, i., 704. 



COMEDO. 141 

The demodex fottieulorum, a harmless parasite, is very often 
found in the plugs of sebaceous matter. This is long and 
worm-like, with a head, a thorax with four pairs of short, 
conical, three-jointed feet, with minute claw-like extremi- 
ties, and a long, tail-like abdomen, which tapers off into a 
blunt and rounded point. (Fig. 15.) 

Yon During 1 has endeavored to show that the double 
comedo is always an acquired formation, and is the result 
of a destructive process between the ducts of two neigh- 
boring glands, so that the two ducts become one, and that 
the destructive process has affected only one gland, while 
the other one is still active enough to produce the comedo 
plug. 

Diagnosis. There is little difficulty in recognizing the 
disorder. Powder grains in the skin are under the skin 
and cannot be squeezed out. 

Treatment. The same constitutional conditions being 
met with in comedones as in acne, we need not repeat 
here what is said there in regard to their general treat- 
ment. 

Fig. 16. 




Piffard's comedo-extractors. 

The local treatment consists in pressing out the come- 
dones and stimulating the skin to a more healthy action. 
There is little use in doing the first without the second, 
as the comedo would be sure to re-form. The comedones 
come out most readily after the free use of soap and warm 
water. Then they may be pressed out between the thumb- 
nails, or by means of an old watch-key, whose sharp edges 
have been worn down ; or by means of either of the 
comedo-pressers of Piffard (Fig. 16) or the comedo-scoop 
of Fox (Fig. 17). With some practice they may be re- 
1 Monatshefte f. prakt. Dermat., 1888, vii., 401. 



142 DISEASES OF THE SKIN. 

moved by pressing the back of a small dermal curette 
against one side of the follicle mouth and making a quick 
turn of the end about them. Violent attempts at removal 
should not be made, as they may cause inflammation on 
account of too much irritation. If the comedo does not 
come out readily, wait until another time. 

Fig. 17. 



Fox's comedo-scoop. 

Frictions with green or soft soap and water are excellent 
as a stimulating remedy, care being taken not to set up 
too much reaction. Hardaway recommends : 

R Saponisolivasprseparat., I -- -. -- -, e i 

Aicohoiis, } aa fj; aal6 

Aquae rosae, ^vj ; 100) M. 

To be rubbed in with a piece of dampened flannel every 
night. He regards the use of sulphur preparations as 
tending to cause comedones, and hence objectionable. Al- 
coholic and astringent lotions of boric acid, alum, or zinc 
are useful. 

Sulphur and most of the preparations given under acne 
are useful. At times the sulphur preparations seem to 
increase the trouble, and have to be abandoned in favor of 
mercurials. 

The best prophylactic measure is the daily washing of 
the face with soap and water, combined with massage. 

Condyloma. See Verruca and Syphilis. 

Congelatio. See Dermatitis calorica. 



Corn. See Cls 



IVUS. 



Cornu Cutaneum vel Humanum. Synonyms : (Fr.) Corne 
de la peau ; (Ger.) Hauthorn ; Cutaneous horn. 

This is a rare disease of the skin, in which there grows 
a horn-like excrescence resembling, often in a most striking 
manner, an animal's horn. Horns vary greatly as to size. 



CUTIS ANSERINA. 143 

They may attain the length of a foot and a diameter of 
fourteen inches at the base, and are usually single, but may 
be multiple. They may be straight, but usually are bent 
or twisted ; they may be laminated, striated, or fibrillated ; 
they may be yellowish, dirty gray, green, brown, or black ; 
they are solid and hard, but not smooth and shining like 
animals' horns often are ; and they have rounded or 
truncated ends. They are not painful unless pressed on. 
When torn or knocked off they expose a raw and bleeding 
surface at the base. Sometimes they fall spontaneously or 
as the result of some inflammatory process. Usually they 
re-form. Most of them occur upon the head, nose, face, or 
scalp. They may occur elsewhere, as upon the extremities 
or male genitals. Their bases may become the sites of 
epithelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. They seem to be 
warty growths that have undergone corneous transforma- 
tion. 

Treatment. The treatment consists in tearing them 
off, under an anaesthetic if large, curetting the base, and 
applying a caustic agent, such as a chloride of zinc paste 
or pyrogallic acid. 

Couperose. See Rosacea. 

Craw-craw is a disease of uncertain nature, met with in 
the tropics, specially on the west coast of Africa. It may 
be papular, vesicular, or pustular, the lesions being dissem- 
inated or grouped. Itching accompanies the lesions, and 
crusts form from the scratching. Ulceration sometimes 
takes place. Both whites and negroes are attacked, but 
chiefly the latter. Several kinds of parasites have been 
found in connection with the disease, specially a species of 
filaria. 

The teeatment consists in removal of the crusts and 
erasion of the soft tissues beneath, as well as of all other 
lesions, and the application of an antiparasitic. 

Crusta Lactea. See Eczema capitis. 

Cutis Anserina, or Goose-flesh, is that condition of the 



144 DISEASES OF THE SKIN. 

skin in which, on account of the action of cold causing a 
contraction of the arrectores pilorum muscles and eleva- 
tion of the hair follicles, it feels rough and looks as if 
studded over with minute papules. It is a fugitive affair, 
therein differing from keratosis pilaris, which, though re- 
sembling it, is constant. 

Cutis Pendula. See Dermatolysis. 

Cutis Tensa Chronica. See Scleroderma. 

Cutis Unctuosa. See Seborrhcea. 

Cysticercus Cellulosae Cutis. At times the larvae of the 
tapeworm become lodged in the subcutaneous tissues and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 
smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals 
die, and the tumors shrivel up and become hard nodules, 
or they may be absorbed. They simulate gummas, lipo- 
mas, sarcomas, carcinomas, and sebaceous cysts. In a 
doubtful case excision or puncture of one of the tumors 
will show under the microscope either one of the larvse 
curled up in its shell, as it were, or the booklets in the 
fluid that escapes. 

Dandriff or Dandruff. See Dermatitis seborrhoica. 

Dartre Farineuse, Furfurac^e, or Volante. Old terms 
for Pityriasis and Eczema. 

Darte Rongeante. See Lupus vulgaris. 

Dartrous Diathesis. This term, though still used by 
French writers, is of very indefinite meaning. Dunglison 
defines it as "a peculiar state of health, which renders its 
subject liable to general eruptions of different forms, which 
are always met with in the young, are symmetrical and 
controlled by arsenic." It is supposed to be the under- 
lying cause of eczema, herpes, seborrhcea, psoriasis, and 
not a few other diseases. 

Defluvium Capillorum. See Alopecia. 



DEBMATALGIA. 145 

Defoedatio Unguium. See Nails, degeneration of. 
Delhi Boil. See Aleppo boil. 

Dermatalgia. Synonyms : (Fr.) Dermalgie ; (Ger.) 
Hautschnierz, Hautnervenschnierz • Neuralgia or rheu- 
matism of the skin. 

By this term is meant spontaneous pain in the skin, 
without any appreciable alteration of the same. The pain 
is variously described by patients as boring, pricking, or 
burning ; or numbness or coldness may be complained of. 
It is constant or intermittent in character and sometimes 
so severe as to be agonizing. It is generally sharply lo- 
cated in a certain region, but it may be general. The hairy 
parts are those most often affected, as the scalp. The legs 
and back, and palms and soles are also not infrequently in- 
volved, as may be any part. Hyperesthesia or anaesthe- 
sia may be present at the same time. Deep pressure may 
or may not relieve it. It disappears of itself after weeks 
or months. 

Etiology. It is a neurosis that may be idiopathic or 
symptomatic. The idiopathic form is rare, and its etiology 
obscure. The symptomatic form occurs in dyspepsia, loco- 
motor ataxia, rheumatism, syphilis, malaria, diabetes, hys- 
teria, chlorosis, and after zoster. According to Hyde, it 
may be a sign of the approaching menopause. The ma- 
jority of its subjects are women. 

Diagnosis. Dermatalgia differs from neuralgia in 
being more superficial and in being accompanied by hyper- 
esthesia. It differs from hyperesthesia in being a spon- 
taneous pain, while the latter is pain only upon contact. 

Treatment. If we can remove the underlying cause, 
we shall cure the trouble, so our remedies should first be 
addressed to it. In any case the patient demands some- 
thing to relieve the pain. In the way of internal remedies 
we can use salicylate of sodium, quinine, antipyrine, phena- 
cetine, some form of opium, hyoscyamus, valerian, and 
other like drugs. Externally, relief may be obtained by 
galvanism, blistering, a mustard leaf over the center from 
which emanates the nerve (Crocker), hot or cold water in 
a rubber water-bag, either alone or alternately ; rubbing 



146 DISEASES OF THE SKIN. 

in Squibb's oleate of mercury or morphine, menthol pencil, 
chloroform liniment, tincture of aconite, and the like. 

Dermatitis Blastomycotica. Under the name of pseudo- 
lupus or blastomycetic dermatitis, T. C. Gilchrist and W. 
R. Stokes 1 described a disease that has been recognized for 
a long time and regarded as a lupus, or at least a scrofulo- 
derm. Since the publication of their observations some 
seventeen cases of the disease have been reported, mostly 
by dermatologists of the United States. J. N. Hyde 2 has 
made the most thorough studies of the affection, and on his 
writings this account is founded. 

Symptoms. The disease usually begins as a split-pea 
sized round papule which may change into a pustule. New 
lesions crop up or the original lesion slowly enlarges in one 
or several directions so as to form a patch or patches. 
These may be papillomatous in character, on a reddened 
base and with a sharply defined border, with crusts, and 
resemble very closely patches of tuberculosis verrucosa. 
Or the disease may creep over the skin, healing as it goes, 
and leaving a thin, white, atrophic cicatrix. Or ulcera- 
tion progresses beneath the patch, causing great destruction 
of tissue. The course of the disease is very chronic. 

The disease occurs on the face, neck, scrotum, hand, 
wrist, and lower extremities. 

Etiology. Invasion of the skin by the yeast fungus 
is the cause of the disease. The majority of the patients 
are men, and all are of middle age. Tuberculosis was 
present in some of the patients. 

Pathology. There are many miliary abscesses, in 
most of which the fungus is found. There are also hyper- 
trophy of the epithelial layer of the skin, a large number 
of polymorphonuclear leucocytes, and giant cells resembling 
those found in tuberculosis. 

The parasites have a capsule, a transparent zone, a cen- 
tral protoplasmic mass, and a vacuole within the protoplasm. 
The organism multiplies by budding, the buds being of all 

1 Johns Hopkins Hosp. Rep., 1897, viii., 46, and Journ. Cutan. and 
Gen.-Urin. Dis., 1897, xv., 393. 

2 Diseases of the Skin. Philadelphia, 1900. 



DERMATITIS. 147 

sizes, several often starting from the mother body at the 
same time. 

Diagnosis. From tuberculosis verrucosa blastomycetic 
dermatitis differs in its more rapid course, its wider spread, 
and the halo about it being less violet in color. But an 
appeal to the microscope is the only reliable means of 
diagnosis. 

Treatment. The iodide of potassium in large doses 
exerts a remarkably ameliorating influence on the dis- 
ease, but radical destruction of the patch by the curette 
or its ablation by the knife is the most reliable curative 
agent. 

The prognosis is bad if blastomycotic septicaemia sets 
in. Otherwise a cure should result if the disease is sub- 
jected to treatment early in its course. 

Dermatitis Bullosa. See Epidermolysis. 

Dermatitis Calorica is the inflammation of the skin pro- 
duced by heat or cold, and divides itself naturally into two 
divisions, viz., D. ambustionis and D. congelationis. 

Dermatitis ambustionis is the eifect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and pro- 
longed action of the heat and the resistance of the skin 
will be the damage inflicted on the skin. A slight degree 
of heat gives rise to a passing erythema. Burns are due 
to a greater amount of heat, and are described for conven- 
ience as being of three degrees. In the first degree the 
skin is reddened, hot, and somewhat swollen ; in the second, 
the damage is greater and vesicles and bullae are formed ; 
and in the third, there is complete destruction of the skin 
followed by gangrene. There is always considerable pain 
with any burn, and if of great extent we have rise of 
temperature and shock. Extensive burns may be dan- 
gerous to life even if not of very high degree, and burns 
involving one-half the cutaneous surface are generally fatal. 
The cause of death in such cases is uncertain. One theory, 
as put forth by Lustgarten, 1 is that it is due to a toxin de- 
veloped by the lodgement of micro-organisms of putrefac- 
1 Med. Eec, 1891, xl., 152, 



148 DISEASES OF THE SKIN. 

tion upon the eschar, probably a ptomaine similar to mus- 
carin. Some of the other theories are nerve-shock, ulcera- 
tions of digestive tract, nephritis, decomposition of the red 
blood-globules ; but no one of these is satisfactory in all 
cases. 

Treatment. The treatment of severe burns commonly 
falls into the hands of the surgeon. In simple burns the 
pain may be relieved by painting them with a five to ten 
per cent, solution of cocaine, and then applying Carron oil, 
consisting of equal parts of linseed oil and lime-water, to 
which may be added five per cent, of carbolic acid, ab- 
sorbent cotton being soaked with the oil laid over the 
bum and covered with impermeable rubber tissue. This 
forms an admirable dressing that may be left on for several 
days, if care is taken to disinfect the part thoroughly be- 
fore applying it. If this is not at hand, the part should 
be dusted thickly with flour or cornstarch until it is pro- 
cured. Or the burns may be covered with a varnish of 
linseed oil and wax, containing five per cent, of salicylic 
acid. Or they may be powdered with bicarbonate of 
sodium or any of the antiseptic powders. Or the bulla? 
and vesicles may be opened and the surface painted with a 
two to five per cent, solution of picric acid. The excess of 
fluid is to be drained off and the surface covered with rub- 
ber tissue or soft gauze that is to be left on for two or 
three days. Deep and extensive burns must be treated 
on surgical and strictly antiseptic principles. Lustgarten, 
in the paper referred to, recommends the administration 
of atropine as a physiological antagonist to the ptomaine, 
the removal of necrotic portions of skin, and dressing the 
wound with carbonate of magnesium, one part, and oleum 
nisei, two parts. All cases of any magnitude demand 
absolute rest in bed. The continuous water-bath of Hebra 
is excellent where it can be had. 

In sunburn the application of cold cream and a dusting 
powder or calamine lotion is usually sufficient. As a pre- 
ventative the skin may be anointed with the grease paint 
used by actors, preferably one of brown color. A calamine 
lotion, used freely, is one of the most efficient and agreeable 
agents for preventing sunburn. 



DERMATITIS. 149 

Dermatitis congelationis, or " frostbite," is the action of 
cold upon the skin. Like heat, cold produces varying 
degrees of damage to the skin ; if not very intense, the 
effect is an erythema — " erythema pernio," " chilblain " — 
which is passing. These are seen upon the hands, feet, 
and face as bluish or purplish-red, circumscribed patches, 
which are cool to the touch, but are accompanied by a feel- 
ing of heat, smarting, or burning, both while forming and 
when the parts again become warmed. To those predis- 
posed to chilblains, dampness accompanied by only very 
moderately cool temperature is sufficient to produce them. 
Hutchinson speaks of the chilblain diathesis to indicate 
the condition found in these people. Their circulation is 
poor, and they are anaemic. Greater degrees of cold at 
first cause the parts to look white, dead, and wrinkled. 
When the cold is lessened redness and swelling supervene. 
Longer exposure may produce bulla? and vesicles, or gan- 
grene, either on account of prolonged anaemia or inflamma- 
tory reaction from too sudden warming. Fingers, toes, 
nose, or ears may be lost in consequence, mortification 
setting in. Death may result from septicaemia. 

Treatment. The best preventive treatment of chil- 
blains is the wearing of woollen coverings on the affected 
parts, and endeavoring to improve the general health of 
the patient and to quicken his circulation. To the latter 
end we may use warm foot-baths, containing salt, at night, 
followed by frictions with alcohol. When they occur 
stimulation is necessary, for which we may use iodine, 
either in tincture or ointment ; ichthyol, twenty to fifty 
per cent, in water ; or equal parts of camphor and bella- 
donna liniment ; or — 

R 01. caiuputi, "I -- „•• -- of 

t • J ^ j- ^ Y aa Zn ; aa 8 

Liq. arnmon, fort., j " a ov > 

Sapo. liniment, co., ad giij ; ad 100| M. 

or simple frictions. Care should be taken in severe frost- 
bites not to allow the parts to become warm too rapidly, 
and nothing is better than rubbing them with snow while 
the patient is kept in a cool room. When sloughing or 
ulceration is begun it must be treated on surgical prin- 
ciples. 



150 DISEASES OF THE SKIN. 

Dermatitis Contusiformis. See Erythema nodosum. 

Dermatitis Epidemica. Under this name Savill 1 has 
reported the occurrence, in Paddington Infirmary, of a 
number of cases of an apparently contagious disease of the 
skin, that began either as a discrete papular eruption, or 
as erythematous blotches like erythema nodosum or papu- 
losum, or as small, flat papules enlarging at the periphery 
and spreading like ringworm. This stage lasted three to 
eight days. It was followed by the second stage, which 
was one of exudation or desquamation, and lasted three 
to eight weeks. However the disease began, the lesions 
soon ran together and formed a crimson surface of thick- 
ened and indurated skin, continually shedding its cuticle 
in scales or flakes of various sizes, sometimes mingled with 
drier exudation. In the second stage it assumed either a 
moist type, like eczema madidans, or a dry one like pity- 
riasis rubra. About two-thirds of the cases were of the 
moist variety, and almost all at some period showed slight 
moisture, either in the flexures of the joints or behind the 
ears. Continuous exfoliation was present in all the cases. 
The third stage was one of subsidence. By degrees 
the inflammation lessened, leaving an indurated, thick- 
ened skin, with polished brown appearance, which was 
sometimes raw, or parchment-like, smooth and shining, or 
cracked, or purpuric, especially in aged people. 

The disease began most often in the skin-folds of the 
face and upper extremities ; and involved either the whole 
body or limited areas. It generally spread by continuity. 
The hair and nails were all shed. 

The constitutional symptoms were anorexia and pros- 
tration. There was either no change in the body-tem- 
perature or a slight rise in the evening during the height 
of the disease. Itching and burning were marked, and 
there was considerable suffering experienced in those 
cases in which the epidermis was shed. Relapses were 
frequent. Albuminuria was found in half of the cases, 
and death occurred in about 12.8 per cent, of the cases. 

More men than women were attacked, and advanced age 

1 Brit. Journ. Dermat., 1892, iv., 35. 



DERMATITIS. 151 

predisposed to it. A specific micro-organism is thought 
to have been found in it. 

Clinically these cases resemble dermatitis exfoliativa, 
an instance of the contagion of which I have met with. 
Its proper place has not been determined as yet. 

The treatment of the disease was by antiparasitic 
remedies, but was not very satisfactory. 

Dermatitis Exfoliativa. Synonyms : Pityriasis rubra 
(Devergie and Hebra) ; Eczema foliaceum seu exfoliati- 
vum ; (Fr.) Dermatite exfoliatrice ou exfoliative general- 
ised, Herpetide exfoliative, Erythrodermie exfoliante. 

An inflammatory disease of the skin involving the 
whole cutaneous surface, and characterized by redness, 
dryness, and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra 
are used interchangeably by most authorities of the pres- 
ent time. If one reads the description of pityriasis rubra, 
as given by Hebra, and of dermatitis exfoliativa, as given 
by Wilson, he will find that the chief difference between 
them is in prognosis, the first being spoken of as uni- 
formly fatal, and the second as tending to recovery in 
many instances. Further, there are not a few cases of 
general exfoliating dermatitis that follow psoriasis, eczema, 
pemphigus foliaceus, and lichen ruber, that present symp- 
toms identical with those of dermatitis exfoliativa, without 
antecedent disease. It seems justifiable, therefore, to 
divide dermatitis exfoliativa into two varieties, namely, a 
primary and a secondary. 

1. Primary dermatitis exfoliativa or Pityriasis rubra of 
Hebra. 

Symptoms. This disease begins as one or more ery- 
thematous patches in the folds of the joints, upon the 
upper part of the chest, or elsewhere, and these patches 
gradually enlarge. At the same time new patches de- 
velop, and, increasing in size, join the original ones. In 
this way the whole surface may become red within three 
days, or a month or more may elapse before the whole 
surface is implicated. The palms and soles may be un- 
affected for days or weeks. The skin is dry and of a 



152 DISEASES OF THE SKIN. 

bright red at first, without thickening and infiltration, 
the redness lessening and leaving a yellow stain on press- 
ure. In a few days, say from six to twelve, sealing he- 
gins and the skin becomes of a darker red; it may even 
become violaceous. The scales may be large, thin, gray- 
ish, attached at their upper border and loose elsewhere, 
being turned up at their edges. They may be small and 
adherent in the center. The amount of scaling is so 
great that handfuls of scales may be gathered from the 
bed after a night's rest. After a few weeks the epidermis 
may be raised and shed from the hands and soles in the 
form of a continuous sheet, sometimes forming a complete 
cast of the part and leaving a red, dry, glazed surface. 
There is a marked enlargement of the glands in the groin, 
so that the whole packet of glands stands out prominently 
against the red skin. The disease is chronic and the 
sealing constant, though marked with exacerbations. After 
lasting some time there is a certain amount of infiltration 
of the skin, and it seems to grow too small for the body 
and looks stretched and shiny in places. Thus are pro- 
duced ectropion and a puckered condition of the mouth. 
We may also find cracking about the joints and moisture 
in these regions. Furuncles, bulla?, or pustules may 
complicate matters. The hair may be shed from all parts 
and the nails become raised from their beds and shed. 
The mucous membranes participate in the disturbance, the 
tongue becomes markedly red, the lips cracked, and the 
nasal secretions are increased. With the ectropion there 
is conjunctivitis. 

The disease begins in some cases with a chill, followed 
by a fever that may rise to 104° F. Fever is present in 
all cases during the early period, and may continue through- 
out. It is sometimes continuous, with evening exacerba- 
tions ; at other times it is only at night. Diarrhoea often 
is met with, and there may be vomiting, albuminuria, and 
pulmonary congestion. The patient complains of a feel- 
ing of chilliness and of pain, tenderness, stinging, burning, 
or tingling of the skin. There is usually no itching. The 
sensibility of the skin is preserved and the secretion of 
sweat may be normal, or lessened, or increased. The 



DERMATITIS. 153 

duration is very variable. Recovery may take place in 
six months or a year, or the course may be chronic, the 
patient dying either in a few months or after years, by a 
gradual marasmus, though the end is usually hastened by 
pulmonary complications. 

Cases of localized dermatitis exfoliativa have been re- 
ported, but they are rare. The tendency is for the disease 
to become general, though it may take years to do so. 
Cases of a recurrent type have been met with. 

Etiology. We know very little about the causes of 
the disease. It is a disease of adults, and is more common 
in men than in women. It may occur in children. It has 
been thought to be predisposed to by alcoholism, gout, and 
rheumatism. An attempt has been made to trace a rela- 
tionship between it and general tuberculosis. There may 
be a history of scaling skin diseases in the family. At 
present we cannot speak with any certainty as to its eti- 
ology. 

2. Secondary dermatitis exfoliativa. A condition of 
the skin exactly resembling the primary form is seen from 
time to time to follow upon or develop from a psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber. I have 
seen one case follow lichen planus. The too vigorous use 
of chrysarobin has been known to be followed by it. 
These cases differ from the primary form only in their 
antecedent skin disease. Once developed they run the 
same course as the primary form, either becoming well 
quickly or falling into a chronic state from which recovery 
may or may not take place. The prognosis is, however, 
much better in the secondary than in the primary form, 
recovery after two or three months being frequent. 

Crocker states that the disease may occur in children, 
though it is very rare. In them it runs a more acute 
course and is attended by severe constitutional symptoms. 
It is usually of the secondary variety. 

Pathology. Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when 
it has lasted some time the whole depth of the skin is 
involved and eventually there is new connective-tissue 
formation, which subsequently undergoes cicatricial con- 



154 DISEASES OF THE SKIN. 

traction, with abundant pigmentation, hyperplasia of the 
elastic fiber bundles, and obliteration of the skin append- 
ages. (Crocker.) 

Diagnosis. When the features of the disease, as laid 
down in the definition, are remembered, there should be 
no difficulty in recognizing it. No other disease involves 
the whole surface in a uniform dry and scaling redness. 
It differs from 2 )S0} 'i as i s m being universal, in an entire 
absence of thick, silvery-white scales, and in leaving a 
smooth red surface when its papery scales are removed. 
Should it be secondary to a psoriasis, there will be no 
difficulty in obtaining a history of that disease. It differs 
from eczema in being a dry disease, with little infiltration, 
in its large papery scales, and in itching but slightly. 
Eczema may be almost universal, but some places are apt 
to be spared ; there is always moisture of a sticky sort 
present somewhere or a history of the same ; its scales are 
small and its itching intense. It differs from pemphigus 
foliaceus in an absence of flaccid bullae. It differs from 
lichen ruber in an entire absence of papules and in the 
whole course of the disease. All these diseases may be 
general, but it is exceedingly rare for them to become uni- 
versal, and it is always possible to obtain a history of their 
having been present at some time in a case of secondary 
dermatitis exfoliativa. It is hardly likely that scarlatina 
could be confounded with dermatitis. A few days' Match- 
ing would in any event decide the question. 

Treatment. The results of treatment of this disease 
leave much to be desired. Many internal and external 
remedies have been tried, but they all are of very uncer- 
tain value. There is no doubt that the patient is most 
comfortable when the skin is w T ell oiled, and vaseline of 
good quality or pure olive oil answers well for this purpose. 
The general health is to be watched over, iron and quinine 
administered, and care exercised to preserve the strength 
by judicious feeding without stimulation. Diuretics may 
be given with the idea of relieving the congestion of the 
skin. Carbolic acid has been recommended, but in my 
hands proved worse than useless in one case. Pilocaqnne, 
or jaborandi, is recommended by Hardaway in acute cases. 



DERMATITIS. 155 

Arsenic should not be given till late in the disease, if at all. 
Crocker recommends enveloping the body in calamine 
lotion, and giving bicarbonate of potassium every four 
hours in twenty-grain doses, with twelve grains of citric 
acid and three to five grains of quinine, the whole taken 
while effervescing. Sherwell has reported several cases 
cured by the continuous use of linseed oil, both internally 
and externally. The patient is to chew or take in milk 
several ounces of flaxseed in twenty-four hours. He is to 
be kept in bed with a rubber sheet under him, and to be 
saturated, as it were, in crude linseed oil. If the oil is not 
used abundantly, it is worse than useless. This plan of 
treatment worked admirably in one of my cases. Thyroid 
extract has proved helpful in some cases. In one of mine 
it aggravated the disease, and the patient made a good re- 
covery after it was stopped, and she was treated with vas- 
eline, soda baths, and careful feeding. 

In the primary form, or pityriasis rubra, treatment 
usually only alleviates the sufferings of the patient, but 
does not cure the disease. 

Dermatitis Exfoliativa Neonatorum is a disease of new- 
born children, first described by Ritter von Rittershain, 1 
and said by him to be quite often seen in the foundling 
asylums of Prague. 

Symptoms. It begins at the mouth as an erythema, 
and thence spreads to the trunk and extremities. Then 
the epidermis raises itself from the cutis, rumples, and 
spontaneously exfoliates in large folds leaving a dry skin, 
or there may be exudation under the epidermis* It be- 
gins usually between the second and fifth week of life, 
and lasts seven or eight days. Relapses may occur. 
There is no fever nor digestive disturbances. Furuncles, 
abscesses, or phlegmonous infiltration, with gangrenous 
destruction, may follow. Recovery takes place in about 
half the cases. It is supposed to be a pysemic condition 
of the skin. 

Treatment. Alkaline lotions will prove beneficial in 
the early stage. Later, a protecting ointment, such as 
1 Arch. f. Kinderheilkunde, 1880, i., 53. 



156 DISEASES OF THE SKIN. 

that of oxide of zinc, or simple vaseline, followed by corn- 
starch, will be indicated. 

Dermatite Exfoliative Aigue Benigne. See Erythema 
scarlatiniforme. 

Dermatitis Gangrenosa or Sphaceloderma. Gangrene 
of the skin may be due to a great variety of causes. Many 
cases are due to purely local causes, such as burns, bruises, 
compression, chemical action, and the like. It is seen in 
the course of diabetes, albuminuria, and some cardiac dis- 
eases ; with degenerative changes taking place in the vas- 
cular walls of arteries, or plugging of their lumen ; and 
in connection with other skin diseases, as carbuncle. Be- 
sides these we have a group of little-understood cases of 
gangrene, due, apparently, to nervous influences, and oc- 
curring in connection with diseases of the nervous sys- 
tem. These may occur anywhere, and may be superficial 
or deep. They behave like surgical gangrene, and are to 
be treated on the same principles. Other cases have been 
reported as following upon some slight injury, such as run- 
ning a needle into a finger. The lesions run up the arm 
or leg in the form of papules that soon change into flaccid 
vesicles, which rapidly crust and form an eschar. When 
the crust falls a depressed cicatrix is left. The process 
tends to last a long time with many relapses. It is always 
to be borne in mind that gangrene occurring in hysterical 
women is apt to be self-imposed. If such cases are care- 
fully noted, it will be observed that the spots appear 
where they can be reached most readily by the patient's 
right hand, or left if she be left-handed. A case of that 
sort was recently seen by me, which rapidly became well 
as soon as I told the girl that she knew the cause of the 
trouble as well as I did, and need have no more of it un- 
less she wished. 

Treatment. In all these forms of gangrene attention 
must be given to the general health of the patient and the 
lesions must be treated on general antiseptic principles. 

There are two forms of cutaneous gangrene that have 
received special names that must be noticed here. They 



DERMATITIS. 157 

are : 1 . Symmetrical gangrene, or Raynaud's disease ; and, 
2. Dermatitis gangrenosa infantum. 

1. Symmetrical gangrene. This was first described by 
Maurice Raynaud/ and since then has been observed by 
others, although it is a very rare disease. It most often 
attacks the second and third phalanges of the fingers and 
toes, next most frequently the nose and ears ; but any part 
may be affected. The parts- become pale or blue and hard, 
and then swell. They feel numb, but the patient may ex- 
perience darting or stabbing pains in them. If pricked, 
no blood escapes. The process may stop here and the 
parts may return to their normal state ; or after a time, 
hours or weeks, they become black, a line of demarcation 
forms, and separation of the affected part takes place. 
The process may stop short of the complete destruction 
of the part and recovery may take place, though relapses 
are liable to occur. It may result simply in a peculiar 
induration and thinning of the fingers. The disease is 
symmetrical. It may involve all four extremities, but 
usually only two are affected. Bulla? may form. The 
nails may fall. 

Etiology. Men are more often affected than women. 
People of all ages are liable to it. Exposure to cold 
seems to be a causative factor, and not a few of its vic- 
tims have been subject to chilblains or other symptoms 
of poor circulation. The malarial and other cachexia 
and the gouty habit have been supposed to be predisposing 
causes. It is probably of neurotic origin. 

Treatment. The internal treatment that has done 
best has been the administration of quinine and belladonna. 
Locally, galvanism may be tried, as it has done good. 
Stimulation by means of lotions of various kinds may be 
tried. Cold applications are said to be better than hot. 
If gangrene has occurred, it must be treated on surgical 
principles. 

Prognosis. The outlook is not good. Death may re- 
sult in those who are not robust. Even if one attack is 
recovered from, another is apt to occur. 

2. Dermatitis gangrenosa infantum (Crocker). Syno- 
1 These de Paris, 1862. 



158 DISEASES OF THE SKIN. 

nyms : Varicella gangrenosa (Hutchinson) ; Pemphigus 
gangraenosus (Stokes); Rupia escharotica (Fagge) ; Ec- 
thyma infantile gangreneux (Pineau) ; Gangrenes multiples 
cachectiques tie la peau ; Ecthyma terebrant de l'enfance 
(Baudouin). 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 
after other diseases of the skin in children, such as variola, 
purpura, erythema nodosum. It consists essentially in the 
formation of deep or superficial round or oval ulcerations 
beneath a black slough, following upon a varicella or other 
pustule. The lesion when fully formed may be one inch 
or more in diameter, and three-quarters of an inch deep. 
The wider the slough, the deeper is the ulcer. Around 
the slough is a red areola. Crocker says that if the 
gangrene occurs while varicella is still present, it begins 
on the head or upper part of the body, and then looks 
like a vaccination pustule ; while if it begins late in the 
course of the disease, the lesions will be located on the 
lower half of the body, especially the buttocks and thighs. 
In the latter case the affected parts are riddled with ulcers 
of all sizes, shapes, and depths. If several ulcers run 
together, very large and irregular ones may form. If the 
lesions are extensive or numerous, they may cause death 
very frequently by pulmonary complications. 

Etiology. Infants and young children under three 
years of age are those affected by this disease, and most of 
them are girls. Debilitating diseases, such as congenital 
syphilis, tuberculosis, and scrofula so called, predispose 
to the disease. In my service at the Infants' Hospital 
on Randall's Island cases of this sort were not infrequent. 
In an epidemic of varicella, occurring in 1890, two cases 
were met with, one quite extensive upon the upper part 
of the back. The children received in the institution are 
from the lowest dregs of our population, and the disease 
seems to be a product of several dyscrasic conditions plus 
a possible mierobie infection. 

Treatment. The cases are to be managed upon gen- 
eral principles. Tonics, fresh air, good food, and hygienic 
surroundings, and remedies addressed as far as may be to 



DERMATITIS. 159 

the underlying constitutional condition are the best means 
for combating the disease. Crocker recommends quinine 
and sulpho-carbolate of sodium, five grains every three 
hours. Locally, the Randall's Island cases were treated 
with iodoform and antiseptic dressings. Aristol wouM 
probably answer well. 

Prognosis. The prognosis is not good in extensive cases. 
Death is apt to result from lung complications or pysemic 
infection. 

Dermatitis Herpetiformis. This name was first sug- 
gested by Duhring, 1 of Philadelphia, for a disease which 
is characterized by great multiformity and marked group- 
ing of the lesions ; by pruritus of varying intensity ; by 
chronicity of course; and by a strong tendency to relapse. 
Under it he includes the hydroa of Bazin and Tilbury Fox, 
the herpes phlyctsenodes of Gibert, the herpes gestationis 
of Bulkley, pemphigus pruriginosus and circinatus, pem- 
phigus a petites bulle, hydroa bulleux, and the herpes cir- 
cinatus of Wilson. Though the name has been adopted 
generally, the exact status of the disease has not been set- 
tled. The account of the disease given here is based upon 
Duhring' s writings. 

Symptoms. In severe cases there may be prodromata 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or 
these alternating, and itching. In mild cases these are 
absent. The onset of the disease may be gradual or 
sudden — the latter not infrequently. The eruption may 
be diffused over the greater part of the general surface, 
or it may be in localized patches. Itching and burning, 
which are severe, precede or accompany the outbreak. 
It may begin as an erythematous, vesicular, bullous, pus- 
tular, or papular eruption, or by a combination of two or 
more of these, the multiformity being a characteristic. It 
shows a tendency for one variety of lesions to pass over 
into another, either during the attack or at some relapse. 
Grouping of the lesions is a marked characteristic of the 
disease. The relapses occur at intervals of weeks or 
1 Journ. Amer. Med. Assoc, 1884, iii., 225, 



160 DISEASES OF THE SKIN. 

months. All regions are invaded, the course is essentially 
chronic, and in pronounced old cases the skin is excoriated 
and pigmented. The mucous membranes may be in- 
volved. 

Dermatitis herpetiformis erythematosa. This form is 
usually of urticarial or erythema-multiforme type, and 
occurs either in patches or diffused. The circumscribed 
patches may coalesce and form larger patches with mar- 
ginate outline. The color varies with the age of the lesion, 
becoming darker with age. There may be maculo-papules, 
flat infiltrations, or vesico-papules. It may continue in 
this way for days or weeks, but usually it changes to the 
multiform type. There is pruritus. 

Demnatitis herpetiformis vesiculosa. This is the form 
most usually met with. The vesicles are from pinhead- 
to pea-sized, flat or raised, irregular or stellate in shape, 
glistening, pale-yellow or pearly, firm, tensely distended, 
and without areola. There may be papules, papulo-vesi- 
cles, vesico-pustules, and sometimes bullae. The lesions 
are disseminated, but aggregated into clusters of two, 
three, or more, or may form groups as large as a silver 
dollar. If thie vesicles are near together, they tend to 
run together and form blebs, which are raised and sur- 
rounded by a pale or distinct red areola, and of a puckered 
or drawn-up appearance. The eruption is usually profuse. 
All regions are affected. Severe itching and sometimes 
burning last until the vesicles are broken, which may not 
be for several days. Sometimes there is a good deal of 
constitutional disturbance. This is Fox's hydroa herpeti- 
forme. 

Dermatitis herpetiformis bullosa. In this form we have 
more or less typical bullae filled with cloudy or serous 
fluid, from pea- to cherry-sized, irregular or angular in 
outline, and with or without an inflammatory base. They 
occur in groups, with red and puckered skin between, and 
more or less vesicles and pustules disseminated over the 
skin. All parts of the body are affected. They come 
out in crops at intervals, rupture in two or three days, 
and crust over. This is Fox's hydroa bulleux. 

Dermatitis herpetiformis pustulosa. This form is less 



DERMATITIS^ 161 

clearly defined than the vesicular form, because vesicles, 
vesico-pustules, and bullae often occur at the same time. 
It may occur uncomplicated and be pustular throughout. 
The pustules are acuminated, round or flat, tense or flaccid, 

Fig. 18. 




Hand of a person affected with dermatitis herpetiformis. (From a replica of 
Baretta's model, No. 1333, in the Museum of the St. Louis Hospital, Paris.) 

and vary in size from a pin-point to a twenty-five-cent 
piece. The large pustules generally have an areola. They 
tend to flatten, spread, and dry in the center, and to group. 
On the trunk we may find a central pustule surrounded by 
n 



1G2 DISEASES OF THE SKIN. 

a variable number of small pustules. They are opaque, 
and whitish or yellowish. There may be slight hemor- 
rhagic exudation into them. They are slow of develop- 
ment, an attack lasting from two to four weeks. There is 
mure marked constitutional disturbance than in the other 
forms. It is accompanied by heat, pricking, and itching. 
It sometimes precedes, follows, or alternates with the other 
forms. 

Dermatitis lierpetiformis papulosa. This is the rarest 
and mildest variety of all, and consists in small or large, 
irregularly shaped, firm, reddish or violaceous papules in 
disseminated groups, the papules being usually excoriated 
on account of the scratching to relieve the severe itching. 
Ill-defined papulo-vesicles are also present. 

Dermatitis herpetiformis multiforme is simply a combina- 
tion of all the preceding varieties, with the type changing 
from time to time. Pigmentation is a feature of this variety 
as well as of all the others, and occurs after the disease has 
lasted for some years. 

Etiology. The disease occurs in both sexes, and is 
supposed to be a tropho-neurosis. It occurs at all ages, 
but most commonly between thirty and sixty years of age. 
My oldest patient was a woman of eighty-two. Little is 
known as to its causes. It occurs quite independently of 
pregnancy, and in one case became better during the same. 
Another case was aggravated during pregnancy, and by 
irregular menstruation. One case seemed to arise from a 
nervous shock. Most cases are seen in the subjects of 
nervous exhaustion of various kinds. By Bazin the gouty 
diathesis was considered to be a predisposing cause of 
hydroa, and hence possibly of dermatitis herpetiformis. 
Winfield has reported four cases in which sugar was found 
in the urine. Occasionally septicaemia may stand in causal 
relation to the disease. 

Pathology. A careful study of herpetiform hydroa 
has been made by G. T. Elliot. 1 This is considered by 
Duhring as one variety of the disease under consideration. 
He shows that the vesicles originate in the epithelium of 
the sweat duets, several being implicated at the same time, 
1 New York Med. Journ., 1887, xlv., 449. 



DERMATITIS. 163 

and that the ordinary signs of inflammation are present. 
He believes that the inflammation is secondary, and is 
seated in the papillary layer of the corium. Degenerated 
nerve-fibers are found, and the disease is believed to be due 
to trophic nerve disturbance. Laredde and Perrin 1 are 
of the opinion that eosinophile cells are closely related to 
the process of bullous formation, and that there is a vaso- 
motor paralysis allowing of the escape of bloody or lym- 
phatic serum in the connective tissue and the formation 
of bulla?. They raise the question of a possible relation 
between renal action and the escape of eosinophile cells. 
T. C. Gilchrist's 2 studies show that in the early stages the 
vesicles are formed beneath the epidermis on account of an 
inflammatory process going on in the corium. He also 
notes the presence of the eosinophile cells. 

Diagnosis. The disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It differs 
from erythema multiforme in not occurring markedly upon 
the backs of the hand, wrists, forearms, and feet ; in its 
more intense itching, instead of the burning of erythema ; 
in its chronicity and greater tendency to relapse ; and in 
its obstinacy to treatment. If the case is watched for a 
time, the character of the eruption will be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture ; in 
the grouping of these vesicles in small clusters ; in its 
herpetic character ; more intense itching ; greater constitu- 
tional disturbance ; and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules ; their 
strong disposition to group ; their slow evolution ; their 
appearance in crops with free intervals ; the chronicity of 
its course ; and obstinacy to treatment. 

It differs from herpes iris by being a general eruption, 
and by not having the groups of vesicles arranged in circles 
about a central vesicle. 

It differs from pemphigus by the grouping of its lesions, 

1 Ann. de derm, et de syph., 1895, vi., 281. 

2 Johns Hopkins Hosp. Kep., vol. i. 



164 DISEASES OF THE SKIN. 

by their more inflammatory, herpetic aspect, and by the 
occurrence of vesicles and pustules at the same time with 
the bullae. If only bullae are present, the diagnosis is 
difficult, 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bulla?. It 
develops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is 
a grave disease, often ending fatally. 

A well-marked case of dermatitis herpetiformis with 
erythematous patches, grouped vesicles, pustules, and bullae 
of stellate form, intensely pruritic and with a myriad of 
excoriations, is so characteristic as to admit of no doubt 
in diagnosis. 

Treatment. This disease is one of the most rebellious 
to treatment, Hygienic measures, fresh air, proper and 
restricted diet, abstinence from all alcoholics, and relief 
from all nervous disturbances must be secured as far as may 
be. Nerve tonics may be given, such as arsenic, strychnine, 
cod-liver oil, hypophosphites, and quinine ; alkaline diu- 
retics, belladonna in full doses, laxatives, all may be tried. 
Phenacetine, five to ten grains, three times a day, has done 
well in some cases. Antipyrine exerts a more powerful 
influence, but is not so safe. Locally Duhring has found 
the best treatment to be sulphur ointment containing two 
drachms of sulphur to the ounce, well rubbed in with vig- 
orous friction as in scabies. In one marked case this treat- 
ment gave most satisfactory results in my hands. The 
frictions should be continued for an hour at a time. This 
plan is not suitable for the erythematous variety. The 
spinal douche acted most favorably in one of my cases. 
Other authorities recommend alkaline and bran baths, dust- 
ing on starch powder with oxide of zinc, Lassar's paste, 
resorcin ointment, liquor carbonis detergens in water, sij to 
sjviij ; calamine lotion, liquor picis alkalinus, tar ointment, 
solutions of carbolic acid, 3j to 3J, dabbed on. Guaiacol, 
five per cent, in ointment base, controls the itching. The 
possibility of systemic poisoning from absorption must be 
borne in mind. Camphor and chloral, one to five per 
cent., combined in ointment or lotion, also controls the 



DERMATITIS. 165 

itching. All these will afford a certain measure of relief, 
but the disease is apt to laugh at our efforts to drive it 
away. 

Prognosis. The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to 
relapse. The course of the disease is essentially chronic; it 
may last for many years ; it shows a strong tendency to 
relapse at longer or shorter intervals ; and, as a rule, does 
not materially affect the patient's health. Old people and 
those not otherwise in good health may be worn out by the 
itching and the discomforts of the disease. 

Dermatitis, Malignant Papillary. See Paget' s disease of 
the nipple. 

Dermatitis Medicamentosa. By this is meant inflamma- 
tion of the skin due to the systemic ingestion of drugs. 
There are a great number of drugs that may cause erup- 
tions upon the skin in susceptible individuals. These ef- 
fects are seen but rarely with some drugs, and quite con- 
stantly with others. The modus operandi of drugs in pro- 
ducing eruptions is probably not the same in all cases. 
Some, doubtless, act by irritating the skin while circulat- 
ing in the blood ; some while being excreted by the glan- 
dular apparatus ; while most of them do so by direct or 
reflex excitation of the vasomotor nerves. Idiosyncrasy 
is marked in all of them. Erythema is the principal feat- 
ure of nearly all drug eruptions, to which may be added 
vesiculation or pustulation. Two drugs, bromine and 
iodine, produce pustular eruptions in nearly all cases when 
ingested. Most drug eruptions appear with more or less 
suddenness, and disappear quite promptly when the drug 
is stopped. They are symmetrical and general in distri- 
bution as a rule. They may be universal or localized. The 
cause of all doubtful eruptions of an erythematous type 
should always be sought for in the ingestion of some drug. 
As a rule, little if any treatment is required for this form 
of dermatitis apart from stopping the drug. Sometimes 
the system becomes accustomed to a drug, and after a time 
does not react unfavorably to it if its administration is per- 
sisted in. With most drugs this is not the case. 



166 DISEASES OF THE SKIN. 

The subject of drug eruptions is so large a one that here 
no more than a skeleton account can be given. For fuller 
particulars the reader is referred to Morrow's masterly 
article in his System of Genito- Urinary Diseases, Sypkilol- 
ogy, and Dermatology, vol. iii., upon which this section 
is founded. 

Acids : Benzoic acid and its compounds may produce an 
eruption of urticaria, maculo-papules, or erythema. Boric 
acid and its compounds may cause an erythematous, psori- 
atic, or erythemato-bullous eruption. The psoriatic form 
is unusual. Carbolic acid causes an erythema that may be 
scarlatinous in character. Nitric acid, in rare cases, gives 
rise to a pustular eruption. Salicylic acid and salicylate of 
sodium produce erythematous, urticarial, vesicular, bullous, 
petechial, or purpuric manifestations. Salol has produced 
urticaria. Tannic acid caused an erythema in one case. 

Aconite gives rise to itching, vesicular, pustular, or bul- 
lous lesions. 

Alcohol may cause a generalized erythema and urti- 
caria. 

Amygdala amara causes erythema. 

Antifebrin may give rise to cyanosis. 

Antimony causes an urticarial or vesiculo-pustular erup- 
tion. 

Antipyrine gives rise to an erythema, consisting of small, 
irregularly circular, slightly elevated patches, which may 
be discrete or confluent, and is at times followed by des- 
quamation. Profuse sweating and itching may accompany 
it, and it affects the chest, abdomen, back, and extremities, 
especially their extensor surfaces. It may be measly in 
character or purpuric. It has given rise also to bullous, 
furuncular, and purpuric eruptions. 

Argenti nitras when used continuously may produce a 
grayish-black discoloration of the skin, or an erythemato- 
papular eruption. 

Arsenic causes erythema of scarlatinal type, papules, 
petechia?, urticaria, vesicles, pustules, zoster, and an ery- 
sipelatous eruption. Itching may attend some of these 
eruptions. Grayish or broAvnish discolorations of the skin 
have followed prolonged ingestion of the drug. Boils and 



DERMATITIS. 



167 



carbuncles have also been produced, as well as thickening 
of the skin of the palms and soles, and that over the 
knuckles, either in the form of diffused keratosis or as 
numerous small corns. 

Belladonna produces a scarlatinal eruption with or with- 
out vesicles and pruritus. As the fauces are often reddened 
the resemblance to scarlatina is striking. It will clear 
up in twenty-four hours, and the eruption is patchy, not 
punctate. Moreover, there is none of the prodroma of 

Fig. 19. 




Bromideof potassium eruption in a child. 

scarlatina nor the strawberry tongue. The pupils may be 
dilated. 

Bromine, in combination with potassium, ammonium, 
and other bases, produces the well-known " bromic acne " 
so commonly seen in the treatment of epilepsy. It is an 
outbreak of dark-red inflammatory papules, papulo- 
pustules, and cutaneous abscesses that bear a close resem- 
blance to acne, and, like it, often leave scars. It differs 
from acne in having a wider distribution and in occurring 
at all ages. This is the most common form of bromine 
eruption, but erythematous, urticarial, papular, ulcerative, 
verrucose, vesicular, and bullous eruptions have been met 



168 DISEASES OF THE SKIN. 

with. Rarer forms are papillary hypertrophy, resembling 
condylomata, and large, irregular, elevated ulcers. It 
would be desirable to prevent these eruptions, but thus far 
there is nothing that will do so with certainty, except stop- 
ping the administration of the drug. Arsenic, or sulphide 
of calcium, or aromatic spirits of ammonia may be tried. 

Calx sulphurata gives rise to vesicles, pustules, and 
furuncles ; rarely to petechia. 

Cannabis indica caused a vesicular eruption in one case. 

Cantharides gives rise to erythematous and papular 
lesions. 

Capsicum may cause erythematous and papulo-vesicular 
lesions. 

Chloral produces erythematous, papular, urticarial, ve- 
sicular, and petechial eruptions. At times the chloral 
erythema bears a strong resemblance to scarlatina. 

Chloralamide causes a general punctate hyperemia with 
vesicular lesions with febrile reaction. 

Cinchona and quinine produce all the primary lesions 
of the skin, though most frequently an erythema of scar- 
latinal type, attended by congestion of the fauces and 
followed by desquamation. 

Conium causes an erysipelatous eruption as well as an 
erythematous one. 

Copaiba and cubebs. Their most common eruption is 
an erythema which is often of a scarlatinal type, but may 
resemble measles, and may be followed by desquamation. 
Outbreaks of urticaria, vesicles, bulla?, or petechia? may 
occur. Pruritus may be present. The odor of the drug 
may usually be detected in the breath. 

Condurango is said to cause furuncles and acne lesions. 

Digitalis produces an erythema of an erysipelatous, 
papular, or urticarial character. 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechia?. 

Guaiacum and gurjun oil cause eruptions like those of 
copaiba. 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 



DERMATITIS. 169 

Hyoscyamus produces an itching erythematous erup- 
tion, with more or less oedema and wheals. Purpura has 
also followed its use. 

Iodine and its compounds, like bromine, give rise to 
a pustular or papulo-pustular, acneiform eruption, usu- 
ally upon the face, back, and upper part of the chest and 
arms ; but often general. This is the most typical form 
of eruption, but an erythema limited to the face and chest 
or general, and urticaria, a vesicular erythema, or an ec- 
zema-like eruption, a bullous form resembling pemphigus, 
as well as carbuncular, petechial, and nodular eruptions, 
may occur. Sometimes there will be more than one type 
present. It is supposed that iodic eruptions occur more 
often in cases in which the kidneys are more or less in- 
active. They sometimes follow the administration of 
very small doses. It is thought that the iodide of so- 
dium is less apt to cause cutaneous disturbances than are 
the other salts of iodine. At times the system becomes 
accustomed to the drug, or the kidneys acting more freely 
relieve the skin. The trouble may be relieved or, to a 
large extent, obviated by administering the salt largely 
diluted with vichy or seltzer water, or by giving it in milk. 
The free use of alkaline diuretics will relieve the skin. 
Arsenic has also been commended, but does no better 
here than in the bromine eruptions. 

Ipecac in one case caused burning heat, with an ery- 
sipelatous eruption. 

Iron is said to produce an acne ; also erythematous, 
vesicular, and urticarial eruptions. The iodide of iron is 
the form that usually produces these eruptions. 

Morphine may cause urticaria, ulcers, a papular, vesic- 
ular, or pustular eruption. 

Nux vomica may give rise to a scarlatina-like erythema 
and a miliary eruption. 

Oleum morrhua? may cause an eczematous eruption or 
an acne. 

Oleum ricini may cause an itching erythema. 

Oleum santali may cause a general petechial eruption. 

Opium causes itching and an erythema resembling scar- 
latina or measles in character, which though often widely 



170 DISEASES OF THE SKIN. 

distributed, is not infrequently limited to certain re- 
gions. 

Phenacetine may cause a general erythematous eruption. 

Phosphorus causes bullous eruptions, and also purpura. 

Pix liquida produces an erythema. 

Potassium chlorate has caused a papular erythema, while 
bluish spots on the skin and a general cyanosis may occur 
after continuous use of the drug. 

Quinine produces a scarlatiniform erythema, as well as 
urticarial, purpuric, vesicular, and bullous eruptions. 

Rhubarb may cause a scarlatiniform erythema. 

Salipyrin has caused oedema. 

Santoninum produces an urticaria or a vesicular erup- 
tion. 

Stramonium gives rise to an itching or burning scarlati- 
noid erythema, a petechial eruption, or an erysipelatoid 
inflammation. 

Strychnine may cause a scarlatiniform rash. 

Sulphonal produces a scarlatiniform erythema. 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tansy has caused a varioliform eruption. 

Tuberculin may cause scarlatiniform or measles-like 
patches of erythema, as well as a psoriasiform eruption. 

Turpentine and terebene may cause scarlatiniform ery- 
thema and a papular and vesicular eruption. 

Veratria gives rise to an erythematous eruption. 

Beside these, Hyde and Montgomery mention the fol- 
lowing drugs as having produced eruptions : anacardium, 
benzol, chinolin, chloroform, cocaine, creosote, duboisin, 
guarana, kava-kava, lactophenin, matico, pimpinella, and 
plumbum. 

Treatment. The treatment of all drug eruptions is 
the same, namely, stopping the use of the drug and giving 
alkaline diuretics. Locally, soothing remedies should be 
applied, such as cold cream, vaseline, and oxide of zinc 
ointment, or preferably alkaline lotions. 

Dermatitis Papillaris Capillitii. Synonyms : Dermatitis 
papillomatosa capillitii ; Framboesia ; Sycosis framboesia 



DERMA TITIS. 



171 



(Hebra) ; Sycosis capillitii (Rayer) ; Mycosis framboesiodes, 
or Acne keloidique, or Pian ruboi'de (Alibert) ; Acne 
keloid. 

Symptoms. This is one of the rare diseases of the skin. 
It begins as an eruption of small-sized papules upon the 
back of the neck at the margin of the hair. They are of 
the color of the skin, or slightly red with an inflammatory 
halo ; exceedingly hard and firm ; and when pricked they 
give vent to a little bloody serous fluid. Increasing slowly 
in number and crowding together, they form raspberry-like 
elevations with uneven, lobulated surfaces. Gradually the 

Fig. 20. 




Dermatitis capillitii. 



disease spreads laterally and also upward upon the hairy 
scalp, even reaching the vertex after months and years. 
After a time the masses may soften a little and contain 
pus. At times they secrete a foul-smelling fluid, and crust. 
Gradually they become sclerosed and keloidal. Pustules 
may form on the hairy scalp, and little tufts of hair pro- 
trude out of them. When they become keloidal they may 
be bald or tufted with hair. Hairs plucked from the 
growths are sometimes normal and sometimes atrophied. 
There may be pain or tenderness, or there may be no sub- 
jective symptoms. 

Etiology. Both men and women are affected, and the 



172 DISEASES OF THE SKIN. 

disease may begin at any age. Negroes seem to be more 
subject to it than the white races. The etiology is obscure. 
It has been suggested that it may be due to the rubbing 
of the shirt collar. 

Diagnosis. If the characteristics of the disease are 
remembered, there should be no difficulty in diagnosis. 
In sycosis we have no hard tumors, and the single hairs 
are surrounded by pustules. Warts are not so hard, do 
not tend to increase in size, and do not become keloidal. 

Treatment. The best treatment is to scrape away the 
small lesions with a curette and excise the larger ones. 
After either operation the base must be cauterized. They 
may be removed with the galvano-cautery. It has also 
been recommended to use sulphur preparations in the early 
stages, and in the later stages to apply a mercurial plaster 
for one to two weeks, alternating it with a ten to twenty 
per cent, resorcin or chrysarobin plaster. 

Prognosis. So far as reported, the growths are benign 
and have no effect upon the health of the patient. They 
are progressive and show no tendency to spontaneous 
recovery. They are obstinate to treatment and prone to 
relapse. 

Dermatitis Repens. Crocker describes this as a spread- 
ing dermatitis, usually following injuries, and probably 
neuritic in character, commencing almost exclusively on 
the upper extremities. It begins about some slight injury, 
as about the finger-nails, and spreads over the affected limb 
with a well-defined, undermined advancing edge. The 
eruption suggests eczema rubrum by its raw, oozing, reddish 
surface, but its sharply defined, undermined spreading edge 
distinguishes it. In some cases it is papular and in others 
bullous in character. It runs a chronic course, sometimes 
leaves a superficial atrophy on healing, and is obstinate to 
treatment. It yields best to antiseptics, such as lactate of 
lead, hyposulphite of sodium, permanganate of potassium, 
salicylic acid, and white precipitate ointment. 

Dermatitis from Roentgen Rays. In some 1300 expos- 
ures to the X-rays the statistics of N. S. Scott ' show that 
1 Ainer. X-Ray Journ., 1897, 1-57. 



DERMATITIS. 173 

there will be one case of dermatitis. The dermatitis does 
not appear until some days or weeks after the exposure. 
The patient first notices an erythematous patch correspond- 
ing to the point of impact of the rays, attended by swell- 
ing of the skin. This is the mildest form and may soon 
disappear. In most cases the part is painful and the red- 
ness increases in area and assumes a purple hue. The 
pain when present is deep-seated and aching. Vesicles 
and sometimes bullae form, and later the central part of the 
patch becomes raw, moist, and tends to remain for months 
without healing. The hair and nails may be shed, but 
they are not permanently lost, as a rule. It is not deter- 
mined what the cause of the dermatitis is, whether the 
generation of ozone, or of heat, or of bombardment of the 
skin with infinitesimal particles of metal. The placing 
of a screen of aluminum gauze between the patient and 
the tube is recommended as a preventative of injury. As 
the cases arise on account of too long exposure with a 
tube placed too near the subject, short sittings and the 
greatest possible working distance would seem to be the 
most rational prophylaxis. 

The treatment is most unsatisfactory and is along sur- 
gical lines. In some cases the patch has been excised in 
the hope of obtaining a healthy surface. 

Dermatitis Seborrheica. See Eczema seborrhoi'cum. 

Dermatitis Traumatica. This term is used to comprise 
all inflammations of the skin that are due to traumatic in- 
fluences, such as blows, rubbing, and the like. It presents 
the usual signs of inflammation to a greater or less extent, 
even up to gangrene, according to the degree of traumatism 
and the susceptibility of the individual skin. The irrita- 
tion of the skin due to scratching is a common instance 
of this form of dermatitis. Under certain circumstances 
it easily develops into an eczema. The chafing of the skin 
met with in horseback riding, in those unaccustomed to 
the exercise, is another common instance. 

Treatment. The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting 
powders, alkaline lotions, or mild ointments, such as that 



174 DISEASES OF THE SKIN. 

of the oxide of zinc. Unna 1 recommends for the preven- 
tion of the dermatitis due to horseback riding, that the 
part should be smeared with a weak resorcin or ichthyol 
ointment. 

Dermatitis Venenata. Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of 
small, closely crowded vesicles that may remain isolated 
or run together and form bullae, are the symptoms that 
constitute this form of dermatitis, the cause of which 
is always some sort of irritant applied to the skin. The 
irritant is usually of a chemical nature, and quite com- 
monly is derived from plants. 

Rhus-pohoning. The most frequent cause of dermatitis 
venenata is contact of the susceptible skin with the leaves 
of the rhus toxicodendron, the poison-ivy, and the rhus 
venenata, the poison-sumach, and the rhus diversiloba, the 
poison-oak. Dr. James C White, 2 of Boston, has written 
a most complete and learned work on the subject, and it is 
to this that the reader is referred for a more detailed ac- 
count of the disease than can be given here. The mildest 
degree of irritation is an erythema. Commonly the reac- 
tion is more marked. The patient first experiences a little 
burning or itching, and attention being drawn to the part 
it is found to be reddened and swollen. In some cases we 
may have wheals. In a few hours papules, then vesicles, 
will form and perhaps bulla?. The swelling may be intense, 
so as, on the face, completely to close the eyes. I have 
seen it so great on the scrotum as to give the appearance 
of an immense hydrocele. The vesicles may be present in 
a countless multitude. The acute developing symptoms 
may last several days, and then gradually subside. The ves- 
icle contents either dry up or discharge upon the skin. The 
parts crust, the swelling and redness slowly disappear, and 
the skin once more becomes normal. When the dermatitis 
is due to the poison-ivy the cause of the trouble is sup- 
posed to be toxicodendric acid. The parts most usually 
affected are the hands and face in both sexes, the penis in 

1 Monatshefte f. prakt. Dermat., 1888, No. 21. 
; Dermatitis Venenata. Boston. 1887. 



DERMATITIS. 175 

the male and the breast in the female — that is, those parts 
that come in direct contact with the poison, or to which it 
is most liable to be conveyed by the hands. In some rare 
cases, and in extremely sensitive individuals, the whole 
body may be affected, and there may be grave constitu- 
tional disturbances. These bad cases are met with in chil- 



Fic4. 21. 






% 



; 



: 




Dermatitis venenata from poison-ivy. 1 

dren whose legs are uncovered. Most persons, perhaps, 
are not susceptible to the poison. Some few are so suscep- 
tible that even having the wind blow on them from over 
one of the plants will cause the dermatitis. 

It is probably not true that the dermatitis will relapse 
after an interval of time, but it has been observed that an 
J From a photograph by Dr, H, W. Blanc, of New Orleans. 



176 DISEASES OF THE SKIN. 

eczema may follow the dermatitis, and that this may show 
a certain amount of periodicity in its outbreaks. White 
says that while the poison may be most active in the 
flowering season, it is sufficiently active at all seasons, and 
that the poison resides not only in the leaves, but also in 
the wood, bark, and fruit. The disease is not contagious 
after the parts have been well washed. 

Diagnosis. The eruption differs from that of eczema 
in seeking the inner sides of the fingers, the hands, face, 
breasts, and genitals ; in the greater amount of swelling 
that commonly attends it ; in the vast number of crowded 
together, " lurid " vesicles ; and in the occasional oceur- 
rence of the eruption in its early stage in streaks, sugges- 
tive of striking against the plant. A history of having 
been in the country will sometimes be an aid in diagnosis. 

Erysipelas of the face sometimes needs to be differen- 
tiated. If the hands or genitals are affected at the same 
time with the face, that will decide in favor of dermatitis 
venenata. Besides this, erysipelas almost always is at- 
tended by constitutional disturbance and it spreads with a 
raised border. 

Treatment. The disease is a self-limited one. It is, 
therefore, natural that there are many " sure cures " for it, 
and nearly every section of the country has some popular 
remedy. A saturated solution of bicarbonate of sodium, 
that can be procured anywhere, will afford relief as promptly 
as anything. The parts are to be kept constantly covered 
with lint or absorbent cotton continuously saturated with 
it or with lime-water. At night we cannot use this if the 
patient sleeps, as the cotton or the lint dries. So it is better 
at this time to use some simple ointment, as cold cream, 
oxide of zinc, or diachylon diluted one-half, the last being 
the best. This treatment commends itself on account of 
its efficacy, cheapness, safety, and accessibility. Ichthyol 
in aqueous solution from ten to forty per cent, strength 
is highly commended by some. White recommends black 
wash (calomel, 3j ; aq. calcis, Oj), applied for half an hour 
at a time, two or three times a day. He cautions against 
the danger of using it in extensive cases. As a substitute 
for it he gives : 



DERMATITIS. 177 

R Zinci oxid., £iv ; 16i 

Ac. carbol., 3J ; 4 

Aq. calcis, ad Oj ; ad 500| M. 

Sugar of lead in solution is a well-known remedy, and 
is efficacious but dangerous. Morrow 1 recommends : 



R Sodii hyposulphjtis, 


fj; 


25 


Glycerini, 


3 ss ; 


12 


Aquae, 


ad Jviij ; 


ad 200 


S. Keep constantly applied. 







After the acute stage has passed the case should be 
treated like an eczema. If the constitutional disturbance 
is marked, the patient should be cared for upon general 
medical principles. 

While the poison-oak, or ivy, causes the symptoms most 
often spoken of as dermatitis venenata, there are a num- 
ber of other plants that will produce like, if not so severe, 
symptoms. Of the commoner ones we find the oleander, 
Jack-in-pulpit, skunk cabbage, bitter orange, May-apple, 
arnica, burdock, golden rod, and common daisy. But 
space will not allow of a complete list of these. Goa 
powder and its derivative, chrysarobin, produce a marked 
dermatitis in addition to the mahogany-staining of the 
skin. The action of croton oil, mustard, stinging-nettle, 
and oil of turpentine is well known. Tar may excite a 
general dermatitis or an acne-like inflammation of the 
follicles called " tar acne," the follicles of the skin being 
stopped up and their mouths filled with a black plug of 
tar. A somewhat similar eruption is seen in workers in 
flax and paraffin. Workers in picking and packing 
peaches may have an eczematous dermatitis developed upon 
the wrists, forearm, neck, and upper part of the chest. 

A great number of chemicals produce dermatitis of 
varying degree. Pyrogallic acid produces burning and 
inflammation, and covers the part with a black coating on 
account of its oxidation. Not only does it destroy dis- 
eased tissues, but it may cause also sloughing of the sound 
skin. Chloroform will blister if prevented from evaporat- 
1 Journ. Cutan. and Ven. Dis., 1886, iv., p. 180. 
12 



178 DISEASES OF THE SKIN. 

ing. This peculiarity is sometimes employed for vesica- 
tion. The strong acids destroy the skin, as also arsenic. 
Sulphur, iodine, iodoform, creolin, mercurial preparations, 
chloride of zinc, bichromate of potash, and caustic potash 
cause varying degrees of dermatitis. Electricity will 
redden and inflame the skin, and not a few cases of der- 
matitis have resulted from wearing clothing dyed with 
aniline dyes. 

Dermatolysis. Synonyms : Chalazodermia ; Cutis pen- 
dula ; Pachydermatocele. 

This term is applied to two entirely different diseases 
of the skin. In one we have folds of loose, thickened 
skin and subcutaneous tissue that sometimes form huge 
masses hanging down from the side of the face, trunk, or 
any part of the body. The skin is soft, and does not ap- 
pear altered, excepting that it is pigmented to a certain 
extent. This form is really a species of fibroma. True 
dermatolysis is a yet more rare affection, in which, owing 
to some defect in the attachments of the skin, it can be 
pulled away from the body like the skin of a cat. The 
" Elastic-skin Man " is an instance of this. There have 
been several of these freaks. The one mentioned could 
pull the skin from his chest up to his eyes. The condi- 
tion is congenital, but can be increased by cultivation. 
There are no other changes in the skin itself. 

Treatment. The treatment of the first variety is by 
excision before it becomes too large. 

Dermatomycosis Furfuracea. See Chromophytosis. 

Dermatosclerosis. See Scleroderma. 

Dermatosis Kaposi. See Atrophoderma pigmentosum. 

Dermatosis Linearis Neuropathic a. See Papilloma lineare. 

Dermographia. See Urticaria factitia. 

Desmoides. See Fibroma. 

Diabetic Eruptions. According to Brocq, they may be 
divided into two great classes: 1. Those in direct rela- 



ECPHYMA GLOBULUS. 179 

tion to alterations in the general economy, such as 
pruritus, chronic papular urticaria, acne cachecticorum, 
erythema, lichen, eczema, herpes, ecthyma, furuncle, car- 
buncle, xanthelasma, gangrene. 2. Dermatoses due di- 
rectly to the contact of the secretions of the body charged 
with sugar, and more especially the eczema of the gen- 
itals caused by contact with the urine. 

Kaposi 1 has described a bullo-serpiginous gangrene of 
diabetics which begins as a disseminated eruption of bul- 
lse upon the extremities. The bullae dry up in the center 
into a black crust, while at the periphery there is a ring 
of fluid pushing up the epidermis. When the crust is 
removed sphacelated skin is exposed, which separates and 
leaves a red, granulating surface. The penis is a favorite 
site for this form of gangrene. It must be treated on 
general surgical principles. 

Distichiasis. This is a congenital or acquired condition 
of the cilia, in which they grow in two distinct rows, the 
inner row being directed inward so as to scrape the cornea. 
According to Michel, generally the outer third of the 
upper lid is affected alone, the deformity is symmetrical 
and bilateral, and of embryonic origin. Electrolysis offers 
the best method of relief. These cases belong to the oph- 
thalmic surgeon. 

Dracontiasis. See Guinea-worm disease. 

Durillon. See Callositas. 

Dysidrosis. See Pompholyx. 

Dystrophie papillaire et pigmentaire. See Acanthosis 

nigricans. 

Ecchymomata and Ecchymoses. See Purpura. 

Ecdermoptosis (Huguier). See Molluscum epitheliale. 

Ecphyma Globulus is described by H. L. Purdon 2 as a 
contagious disease occurring in Ireland. It begins as a 
tubercle which, after a time, softens and is replaced by a 

^Wien. med. Presse, 1883. 

2 Dublin Journ. Med. Sci., 1897, ciii., 486. 



180 DISEASES OF THE SKIN. 

raspberry-like tumor. All parts of the body may be af- 
fected excepting the hands and feet, It is chronic in its 
course, but can be cured by applications of the nitrate of 
silver. 

Ecthyma. Synonyms : Furunculi atonici ; Phlyzacia 
agria ; (Ger.) Eiterpusteln ; (Fr.) Furoncles antoniques ; 
(Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with 
hard, elevated, reddened bases, attended by the formation 
of thick, greenish or dark-colored crusts, and followed 
either by cicatrices or dark pigmented spots. 

Symptoms. Most if not all cases of so-called ecthyma 
are either pustular eczema, or more probably a contagious 
disease allied to if not identical with impetigo contagiosa. 
As usually described, the disease consists in the outbreak 
of one or more round, flat pustules, whose covers are not 
fully distended, and which have an inflammatory areola. 
In size they vary from that of a split pea to that of a finger 
nail, or larger. At first they are white or yellow. Subse- 
quently they may or may not become reddish from the ad- 
mixture of blood. They may dry up, forming a crust, which, 
on falling, leaves a healthy surface. Or they may rupture 
spontaneously or be broken, and form a thick, greenish or 
blackish crust, under which is a raw or superficially 
ulcerated surface, which on healing leaves a pigmented or 
slightly cicatricial spot. In subjects in bad hygienic sur- 
roundings quite deep ulcers may result, These pustules 
are usually discrete, but they may group. They are both 
painful and tender. Any part of the body may be affected, 
but they are most often seen on the extremities, especially 
the legs, where the hair is coarse, the shoulders and the 
back. The course of the disease may be acute, each 
pustule lasting five or ten days, and the whole disease 
lasting about two weeks ; but generally it is chronic, and 
kept up by the outbreak of fresh crops. There is more 
or less itching, soreness, and pain. It is both contagious 
and auto-inoculable. Febrile symptoms may accompany 
or precede the outbreak of the disease, but as a rule they 
are absent. 



ECTHYMA. 181 

Etiology. Dirt, want, bad hygienic surroundings, the 
strumous diathesis, or a broken-down, cachectic condition 
brought on by intemperance or dissipation, all predispose 
to the disease. It is quite often seen in the genus " tramp." 
It follows, not infrequently, upon scratching on account of 
pediculi and scabies. It is most often seen in adults, 
and is rare in children. Like in all other purulent dis- 
eases, pus cocci, both staphylococci and streptococci, are 
found in the pus, and are the contagious element in the 
disease which is carried from place to place to produce 
new foci of infection. 

Diagnosis. Ecthyma differs from eczema in having 
much larger and deeper pustules, which are discrete and 
not confluent, in the marked areola about the pustules, 
and in the absence of all other signs of eczema. It differs 
from impetigo contagiosa in its pustules being deeper ; in 
their location upon the extremities rather than upon the 
face and hands ; in not having that flabby, bullous look 
of a burn of the second degree, so common to impetigo ; 
in having thick greenish or blackish crusts, and not straw- 
colored stuck-on crusts ; in occurring in more or less de- 
bilitated adults and not in otherwise healthy children. But 
all these alleged differences can be readily explained away 
by the difference in the character of the soil on which 
the contagious principle is implanted. Ecthymatous pus- 
tules are often seen in connection with impetigo conta- 
giosa. From impetigo it differs principally in its being a 
deeper and more inflammatory process, and in occurring 
in debilitated subjects. It resembles the large, flat, pus- 
tular syphiloderm ; but its crusts are not heaped up into 
oyster-shell-like masses, as in syphilis, and when they 
are removed they leave a more superficial, and not so 
punched out an ulcer. There are more pain and itching 
in ecthyma, and an entire absence of other symptoms or 
history of syphilis. It differs from furuncle in having no 
central core, and in not being so deep a lesion nor so 
painful. 

Treatment. The first thing to be done in these cases 
is to obtain cleanliness, proper hygienic surroundings, and 
complete abstinence from alcoholics. If there is a general 



182 DISEASES OF THE SKIN. 

debility, touics must be given and the dietary improved. 
Locally, all crusts must be removed with soap and water, 
the lesions dressed with an ointment containing some an- 
tiseptic such as — 

R Hydrarg. amnion., £)j ; 51 

Ungt. zinci oxidi, 3J ; 100 1 M. 

and the parts enveloped in a bandage, where such can be 
applied. An ointment or oil containing ten or fifteen 
grains of salicylic acid to the ounce will also answer well. 
If ulcerations have formed, they should be treated as will 
be indicated under Ulcers. 

Ecthyma infantile gangr^neux. See Dermatitis gan- 
grenosa infantum. 

Ecthyma terebrant de l'enfance. See Dermatitis gan- 
grenosa infantum. 

Eczema. Synonyms : (Fr.) Dartre vive, ou humide, 
eczema; (Ger.) Ekzem, Hitzblatterchen, Flechte, niissende 
Flechte, Salzfluss ; Salt rheum, Tetter, Humid tetter, 
Scall, Scald, Heat eruption. 

A non-contagious, inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with itch- 
ing, descpiamation or loss of the cuticle, and usually with 
the exudation of serous or sero-purulent fluid either be- 
neath the cuticle or upon the denuded surfaces. It may 
present erythema, papules, vesicles, or pustules, and its 
lesions show a decided disposition to run together and 
form infiltrated patches. 

Symptoms. This is a most protean disease. It has 
been well said that if a student learns to recognize and 
treat syphilis and eczema, he has possession of the key to 
the whole of dermatology. There are six prominent 
symptoms of the disease : 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusting or scaling. 

6. Cracking of the skin. 



ECZEMA. 183 

111 every case there will be four or five of these symp- 
toms ; or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and ma- 
laise be present, they are accidental, or an expression of 
that condition of the system that predisposes to the dis- 
ease, and not part of the disease itself. Very often the 
first thing that attracts the patient's attention is itching, 
and when he examines the skin he finds it reddened, and 
either scaly or covered with papules, vesicles, or pustules; 
or moist. 

The tendency of eczema in all forms is to form patches, 
which are infiltrated to a greater or less extent; ill de- 
fined ; shade off imperceptibly into the surrounding skin, 
so that it is hard to say where they end, with outlying 
lesions about them ; irregular in shape ; of all sizes, some- 
times involving nearly the whole cutaneous surface ; some- 
times swollen, and of dark -red color; sometimes with a 
shade of yellow. Beginning by a few lesions, the disease 
increases more or less rapidly in extent, and it is by the 
running together of the individual lesions that the patches 
are formed. It may clear away after a short time, or it 
may last weeks or months, or become chronic, show- 
ing little tendency to recovery. There is no constant 
rule as to the course of the disease, though many cases 
occur and recur at certain seasons of the year ; it 
may be in the summer, spring, autumn, or winter. 
Any or all parts of the skin may be affected, but it 
has a predilection for the flexures of the joints, the 
face, the scalp, and the sulcus behind the ear. There 
may be but a single patch or many patches. It com- 
monly affects both sides of the body, but with no marked 
symmetry. 

The subjective symptoms are itching, burning, and a 
feeling of heat and tension. Of these, the most constant 
is itching, which is present in all cases, and is often so 
great as to cause the patient to excoriate the skin by 
scratching. It is subject to exacerbations and remissions. 
The latter may be complete or incomplete. Burning and 
tension are experienced for the most part only at the 



184 DISEASES OF THE SKIN. 



subacute or chronic case. 

The old definition of the disease was that it is a vesicu- 
lar one. It is well to disabuse the mind of this impression 
at the start, as there is a form of the disease that is dry 
throughout — the erythematous form. There are five forms 
of eczema, known as the erythematous, papular, vesicular, 
pustular, and squamous. Eczema madidans is but a con- 
venient term to describe a very moist eczema. Eczema 
rimosum or rhagadiforme is but an eczema in which there 
is cracking of the skin, especially about the joints. 

Before discussing each of these forms by itself, it is 
necessary to understand that no one of them, excepting 
perhaps eczema erythematosum, is clear cut and unchang- 
ing. On the contrary, the disease may begin as a papular 
erythema ; upon the papules vesicles may form, which will 
run together and soon break down of themselves and form 
a weeping patch ; the subsequent lesions may then be 
pustules, and the final stage through which all varieties 
pass before recovery is the squamous. Now we are ready 
to study each variety by itself. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and in 
children. Beginning as one or more ill-defined red patches, 
it soon forms a continuous patch by the coalescence of the 
smaller ones. Sometimes the whole face is involved, some- 
times there are several patches. The inflammation is often 
attended by oedema to such an extent that the eyes are 
nearly closed if the disease is in their neighborhood. The 
patient experiences great discomfort on account of the 
itching and the burning and stiffness of the skin. The 
skin feels harsh, dry, and thickened; it is swollen; its 
color is bright or dull red ; there are a slight amount of 
small adherent scales and many small excoriations. If 
it occurs on contiguous folds of the skin, there may be 
moisture. Upon the face vesicles and papules may de- 
velop, but they are exceptional. After lasting for a time 
the symptoms may subside and recovery take place, the 
patches fading away altogether and not in the center alone. 
It may assume a chronic form and last for years. It is 



ECZEMA. 185 

seen at times upon the body in the form of very superficial, 
pale-red, scaly, round, circumscribed patches, and consti- 
tutes one form of the so-called parasitic eczema. 

Eczema papillosum. This is the lichen simplex of the 
old writers. It consists in an eruption of pin-point to pin- 
head-sized, bright or dull-red, acuminate, discrete, grouped, 
or perhaps confluent papules. They are often in relation 
to the hair follicles. Very frequently the papules are 
capped by vesicles. The papules may remain discrete 
throughout their course, with an occasional small confluent 
patch to betray the nature of the disease. These patches 
are frequently no larger than a silver dollar in size and 
fairly well defined. This is one of the most itchy varieties 
of this pruriginous disease, and the scratching consequent 
upon it produces excoriations, and, breaking down the 
vesicles and papules, gives exit to the serum and converts 
the patch into a moist one. This variety is located prefer- 
ably on the extensor aspects of the limbs. The life of the 
individual papule is comparatively long — days or weeks. 
It is often obstinate to treatment. 

Eczema vesiculosum is the most common and most char- 
acteristic form, and consists in an eruption of pin-point to 
pinhead-sized, rounded or acuminate vesicles that appear 
upon a reddened surface in immense numbers. Prickling 
and tingling precede the outbreak ; intense itching and more 
or less swelling attend it. The vesicles group, and perhaps 
coalesce, and soon rupture of themselves, and discharge a 
clear, sticky, mucilaginous fluid that possesses the quality 
of stiffening and staining linen, and dries into a light- 
yellow crust. The vesicles rupture so early that it is rare 
for the physician to see a case with the vesicles intact. 
New vesicles form about the patch, and break down ; the 
discharge continues from the sites of the vesicles, and the 
crust continuously forms. A raw surface is exposed when 
the crusts are removed. Sometimes when the crust is 
prevented from forming on account of friction, there is a 
weeping surface, which has been called eczema madidans 
or rubrum. Eventually the discharge ceases, the hyper- 
emia lessens, scaling takes place, and after a time the skin 
returns to its normal condition. This form of eczema 



186 DISEASES OF THE SKIN. 

seeks the soft parts of the skin, the flexures of the joints, 
the flexor surfaces of the limbs, and behind the ears. It 
may involve the whole or nearly the whole cutaneous 
surface. After it has lasted a little while in a part the 
skin is evidently thickened. With it papules and pustules 
very generally are found. 

Eczema pustulomm. Like the pustular syphilide, this 
form of eczema occurs in more or less broken-down, cachec- 
tic, delicate, or strumous subjects. It is the most com- 
mon form of eczema met with in children, and in them 
occurs by preference on the face and head. The eruption 
consists of small pustules that may start as pustules or 
develop from vesicles. They are present in large num- 
bers, and tend to break down and form patches covered 
with greenish crusts. If blood is drawn by scratching, 
the crust will be blackish. They are somewhat larger 
than the characteristic vesicles, and have a fondness for 
hairy parts, though any part of the body may be affected. 
This and the previous form often merge into each other. 
It may develop from any of the other forms of the disease 
on account of infection by pus cocci. It is not so itchy 
as the other forms. It may change into an eczema 
madidans, and it passes through the squamous stage on 
the way to recovery. While the above described forms 
of eczema are in some cases fairly well marked, in very 
many cases several forms will be present at the same time. 
Thus we may see erythematous patches here, while there 
vesicles may form which change into pustules, while scat- 
tered about are numerous papules. 

Eczema squamosum/'m the final stage through which all 
cases pass on their way to recovery. In it the skin is dry, 
red, and covered with thin, papery, flat, large or small 
scales. It is a condition of the skin in which the forma- 
tion of its corneous layer falls short of perfection. The 
disease may continue in this condition for an indefinite 
time, a chronic eczema with occasional exacerbations. 
Then it may pass away entirely and the skin become quite 
well ; or some local injury may cause an acute outbreak of 
eczema. The skin in this form is more or less thickened, 
and deep cracks are liable to form about the joints, be- 



ECZEMA. 187 

cause the infiltration of the skin interferes with its elas- 
ticity, and it breaks instead of stretching when the joint 
is extended. While the patches are usually ill defined, 
in some cases they will be round, and with well-marked 
borders. This form is spoken of as orbicular eczema. 

Eczema may be acute, subacute, or chronic — terms that 
apply not to the length of time that the disease has lasted, 
but to the symptoms it presents. In acute eczema there 
are the usual signs of inflammation — heat, redness, and 
swelling. There may be constitutional symptoms of fever, 
chills, prostration, and the like, in this stage. This stage 
is usually of short duration, and passes over into the sub- 
acute stage. Now the swelling lessens or disappears, but 
there is an active evolution of lesions, papules, vesicles, 
or pustules, as the case may be. After a time the chronic 
stage is reached, when the disease takes the form of red- 
dened, infiltrated, scaly patches. It is prone to take on 
acute symptoms under slight irritations. In severe at- 
tacks of eczema the patient may be confined to bed and 
greatly prostrated. In the great majority of cases, while 
the patient suffers much discomfort, he does not feel ill. It 
predisposes to ulceration upon the legs when combined with 
varicose veins, and then is named eczema varicosum. This 
must not be confounded with a somewhat similarly sound- 
ing name, eczema verrucosum, which is a rare form, in 
which the skin takes on a warty appearance on account of 
a hypertrophy of the papillae. 

Etiology. Like its symptoms, its causes are numer- 
ous. It may arise from purely local causes, but even then 
it is probable that we should assume in most cases a pre- 
disposition on the part of the skin. Thus, we have ec- 
zema of the hands in washerwomen. Perhaps for a score 
of years they had washed in the same water and with the 
same soap without eczema. Then under the same local 
conditions, but with some unknown internal constitutional 
state, an eczema breaks out. Of external irritants, we 
have the sun, water, intense artificial heat, acids, alkalies, 
traumatism, rubbing of apposed surfaces or chafing by 
the clothing, parasites — in fact, just the same things as 
will cause a dermatitis, only now the action goes further, 



188 DISEASES OF THE SKTX. 

and a catarrhal condition of the skin results. Cold has an 
undoubted influence on the skin, and eczema is more com- 
mon in winter than in summer, and is generally aggravated 
by extremely low temperature, even when the patient keeps 
in the house. It has been observed that children with 
eczema grow worse when it is cold and a high wind is 
1 (lowing, even though they are not exposed directly to 
these conditions. Vaccination may act as a local cause. 

Of the internal or predisposing causes, perhaps the most 
common and active is some digestive or intestinal disturb- 
ance — it may he dyspepsia or malassimilation, or derange- 
ment of the liver, or constipation. At other times the 
kidneys are at fault. Diabetes and Bright's disease 
both predispose to eczema. Chlorosis and anaemia, uter- 
ine disorders and the menopause, and the strumous 
diathesis are at times active factors. Derangements of 
the nervous system arc exciting causes ; now and again 
we meet with cases which appear suddenly after some 
nervous shock. Rheumatism and gout and varicose veins 
are other predisposing causes. To most of these internal 
causes some external irritation must be added before the 
eczema appears. 

The French school of dermatology has long held to its 
theory of diathesis, and has taught that the dartrous 
diathesis is the cause of eczema. Outside of France little 
is known about diathesis. A vulnerability of the skin is 
necessary for the production of an eczema, and many 
patients may fairly be regarded as eczematous, just as 
others may be spoken of as gouty, or rheumatic, or psori- 
atic. This peculiarity or tendency of the skin may be in- 
herited, and in so far eczema may be regarded as hereditary. 

The disease occurs in all ages, conditions, races, and both 
sexes, and is the dermatosis we are most often called upon 
to treat. It is especially common in children. In Bulk- 
ley's tables, out of 3000 cases, 676 occurred under five 
years of age ; and of these, 520 were in children under 
three years. Of the remaining cases, 1234 were between 
the ages of twenty and fifty, and were divided about 
equally in each decade. About one-third of all skin dis- 
eases are eczema. 



ECZEMA. 189 

These many etiological factors indicate that it is prob- 
able that our present eczema is a too composite disease, and 
it is for this reason that attempts are constantly made 
to take away certain members of the family and form them 
into separate diseases. Unna and others have asserted of 
late that a parasite, yet undetermined, is the cause of one 
variety of eczema, his eczema seborrhoicum. Thus far 
no micro-organism has been demonstrated as the cause of 
the disease, though the pus cocci are found in the pustular 
form. They are doubtless often the cause of the pustula- 
tion, which may be a matter of secondary infection. Unna 
further teaches that there are two other varieties of the 
disease, one due to reflex nervous irritation, such as is 
seen during dentition of infants, and one dependent upon 
the tubercular diathesis. 

Pathology. Eczema is a catarrhal inflammation of 
the skin, analogous to that of the mucous membrane, which 
has its seat principally in the papillary layer of the skin 
and in the rete. This superficial location of the disease is 
the reason why the skin is left unmarked after the disease 
has been recovered from. In chronic eczema there is 
marked cell infiltration of the corium, producing the 
characteristic thickening of the skin. The subcutaneous 
tissues may be affected by this infiltration. A tropho- 
neurosis is supposed by many to be the cause of the dis- 
ease when not due to local irritants, and Crocker quotes 
Marcacci as having found changes in the sympathetic in a 
fatal case of universal eczema. 

Diagnosis. If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, it will be a great aid in diagnosis. 
To them should be added the tendency the disease evinces 
to locate in the folds of the joints, between apposed surfaces 
of skin and behind the ears, and the peculiar mucilaginous 
quality of the exudate, which stiffens and stains linen and 
glues the hair together. Fortunately, a diagnosis of eczema 
will fit one out of every three cases. Here will be given 
the general diagnosis, reserving for the sections on regional 
eczema the diagnosis of special forms where necessary. 



190 DISEASES OF THE SKIN. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently passes over into it. As a rule, it 
runs a more rapid course, its vesicles are longer preserved, 
bullae are apt to form, there is burning rather than itching, 
and it heals readily on removal of the cause. 

Dermatitis exfoliativa, is, when fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is also 
dry, and has abundant large scales ; while eczema will 
exhibit moisture somewhere, and does not scale so abun- 
dantly. For further points in diagnosis, see under Derma- 
titis exfoliativa. 

Erysipelas is attended by fever and marked constitu- 
tional disturbances, has a sharply defined border, advances 
steadily at its margin, and forms a swollen, deep-red patch 
upon which large vesicles and bullae form. The margin 
of eczema is ill defined, fading off into the surrounding 
skin ; its vesicles are pin-point- to pinhead-sized ; itching 
is always present ; and there is little or no constitutional 
disturbance. Eczema has a dry, rough surface in the ery- 
thematous form, while erysipelas has at first a smooth 
and shining one. 

Erythema burns rather than itches ; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. In 
eczema pressure will cause the redness to disappear, but it 
will leave a yellow stain in its place. Erythema lacks the 
itching, exudation, scaling or crusting, and cracking of 
eczema, is prone to appear upon the back of the hands 
and wrists, and is symmetrical. 

Herpes febrilis resembles eczema only in having vesicles 
upon a red surface. It occurs usually in a single patch 
upon the face ; its vesicles are discrete, and show little 
tendency to run together ; its course is short, and it pains 
or burns, but does not itch. 

Zoster occurs in the form of a number of herpetic patches 
following the course of a nerve, and occupying only one 
side of the body — symptoms that are entirely foreign to 
eczema. 

Impetigo contagiosa occurs for the most part upon the 
face, hands, and exposed parts. Its pustules are large, 



ECZEMA. 191 

flat, and discrete, not small and conglomerate. Its crusts 
are thin and stuck on ; not greenish and thick, as in eczema. 
It is a vesico-pustular disease, and often presents large 
vesicles or bullae that look like burns of the second degree. 

Lichen planus presents papules that are flat, smooth, 
umbilicated, and angular, and has a peculiar violaceous 
hue when its lesions are sufficiently numerous to simulate 
eczema. Eczematous papules are round and acuminate 
and bright red. They are constantly coming and going, 
while those of lichen planus are constant and last for 
considerable time. 

Lupus erythematosus occurs in sharply defined patches 
which are exceedingly chronic ; its scales are adherent ; 
its color is peculiar ; and it produces atrophy of the skin. 
Eczema presents none of these symptoms. 

Mycosisfungoides in its early stage is often indistinguish- 
able from eczema. Usually its patches assume a half- 
moon, horseshoe, or kidney shape. These may disappear, 
to reappear in the same or other locality. They also fail 
to respond to treatment. The diagnosis is at times dif- 
ficult until the characteristic elevated patches appear. 

Pemphigus foliaceus presents raw surfaces that bear some 
resemblance to eczema rubrum ; but its large bullae and 
pastry -like crusts, coupled with the generally bad condition 
of the patient, sharply differentiate it. 

Phthiriasis, or pediculosis, shows paralled scratch-marks 
over the shoulders and excoriations about the waist and 
on the limbs where the seams of the clothing come. If 
on the head, the lesions will be on the occiput, and nits will 
be found on the hair of that region or of the temples. 
The eruption to which they give rise is an eczema, but 
the cause of it is evident. 

Pityriasis rubra pilaris has elevated papules about the 
hair follicles of the back of the fingers, and is not particu- 
larly pruritic. It forms well-defined patches that feel 
like nutmeg graters and present no secondary changes. 

Pruritus cutaneus has no lesions, properly speaking, 
and the excoriations met with are not in patches, but scat- 
tered all over the body at intervals and irregularly. The 
itching is more paroxysmal than it is in eczema, and the 



192 DISEASES OF THE SKIN. 

itching is the only symptom that it has in common with 
eczema, 

Psoriasis, when occurring in typical round or oval, 
sharply denned patches, with silvery scales, offers no dif- 
ficulty in diagnosis from a typical eczema. From circum- 
scribed eczema, that occurs occasionally, it may be diag- 
nosticated by the color — of a brighter red ; by the scaling, 
that is whiter, thicker, and more laminated ; and by find- 
ing characteristic patches either of the one or the other 
disease elsewhere on the body. When psoriasis occurs in 
large areas it is diagnosticated from squamous eczema by 
its sharply defined border ; its marginate form ; its brighter 
red ; its more abundant, thicker, and whiter scales ; its fond- 
ness for the extensor surfaces of the limbs, while eczema 
seeks the flexor aspects and the flexures of the joints ; its 
uniform character and constant dryness, against the poly- 
morphous character of eczema and its moisture ; and its 
history of frequent relapses, always of the same sort and 
always on the elbows and knees. 

Rosacea occupies the middle third of the face from 
above downward, attacking the forehead, nose, and chin ; 
while eczema affects the whole or part of the face, but 
never occurs on these limited regions alone ; it burns 
rather than itches ; it shows telangiectases, and its red- 
ness and occasional discrete, sluggish, superficial pustules 
are very different from either the dry, harsh, scaly red- 
ness of an erythematous eczema, or the crusted surface of 
a pustular eczema. 

Scabies may be diagnosticated from eczema by its loca- 
tion upon the anterior surface of the wrists, between the 
fingers, and upon the abdomen and buttocks of both sexes, 
and upon the nipples and breasts of women and the penis 
of men. In children the feet are often affected. The 
presence of cuniculi is diagnostic, but they are hard to 
find in some cases. Of course, the eruption in scabies is 
an eczema ; but it is important to recognize, where pos- 
sible, the cause of an eczema in order to cure it. 

Syphilis, like eczema, is a protean disease ; but it does 
not itch, and that is an important point in differential 
diagnosis. It is true that occasionally a papular or crusted 



ECZEMA. 193 

pustular syphilide does itch, but the occurrence is so rare 
that it need not here be taken into account. The early 
sypbilides are general eruptions, whether macular, papular, 
or pustular, and the efflorescences never form patches, 
though they may show more or less grouping. When the 
other symptoms of syphilis are present, such as the initial 
lesion, mucous patches, and alopecia, there can be no diffi- 
culty. It is the later manifestations of the disease that 
offer difficulties in diagnosis, and especially the grouped 
papular lesions that occur on the palms in the form of scaly 
patches. In some cases a diagnosis is impossible. The 
most suggestive symptom of syphilis is the occurrence of 
the disease upon the palm of one hand alone. The patch 
will have a wavy outline; will be scaly, but not moist 
or crusted ; will often show healthy skin in the middle ; 
and there are apt to be isolated, scaly, dark-red papules 
somewhere in the neighborhood. The finding of scars 
of old lesions, or some other evidence of syphilis, will 
aid us. 

Trichophytosis corporis when in disk-shaped patches 
that have not formed rings bears at times so close a resem- 
blance to eczema that it is difficult to make a diagnosis at 
once ; but in a short time the center of the disk will clear 
up and the annular ringworm patch will declare itself. 
Eczema does not have annular patches. 

Urticaria, when it has induced itching and has been 
scratched, looks like an eczema. We recognize it by the 
finding of the wheals, or the history of them, and by the 
isolated, scattered distribution of the excoriations and 
papules. Some cases of papular urticaria can only be diag- 
nosticated after prolonged observation. 

Teeatment. While not a few cases of eczema arise 
from purely local causes, and require only external treat- 
ment, in most cases the patient is not in good condition, 
and he needs treatment quite apart from his skin disease. 
It is well for us to begin the treatment of a case by regard- 
ing it as one of a sick man rather than a sick skin. The 
better practitioner of medicine a man is, the better his 
chances of curing eczema will be. It is not the part of 
the writer on matters dermatological to instruct his readers 



194 DISEASES OF THE SKIN. 

in general medicine, and here I can give only an outline 
of the treatment proper to be followed. 

If the patient is anaemic, we should administer iron, 
and see that he has plenty of fresh air and a sufficient 
amount of exercise. If he is rim down, and especially if 
he is of a strumous habit, cod-liver oil will be indicated. 
To the nervous patient, strychnine, hypophosphites, and 
other nerve tonics should be administered. The dyspep- 
tic needs mineral acids, mix vomica, pepsine, or bismuth 
and soda, according to the different form the trouble takes. 
Those suffering from uterine diseases need the treatment 
best suited to their case. The gouty and rheumatic will 
be benefited by alkalies, such as the acetate of potash or 
the phosphate of soda. Colchicum will be useful in gouty 
eases. In fact, there is no specific for eczema, and each 
case should be studied and treated by itself. 

But nearly every case requires attention to the diet and 
exercise, and to the proper action of the bowels and kidneys. 
The diet is of special importance. Piffard 1 has found that 
56 per cent, of his cases of eczema have been carnivorous 
— that is, eating meat three times a day and but little bread 
and vegetables ; 40 percent, omnivorous, and but 4 percent, 
herbivorous. Many of the patients eat too much and ex- 
ercise too little. Many suffer from distress of stomach after 
eating certain articles. Some eat too little, and that of im- 
proper sort. The indications for treatment are therefore 
obvious. The greatest difficulty we have to contend with 
is the objection most people have to dieting of any sort. 

In an acute eczema of any considerable extent it is always 
best to put the patient on a restricted and simple diet, and 
of these, where milk is well borne, a milk diet is the best. 
Two or more quarts of milk may be taken during the day 
in divided doses, with dry toast or toasted crackers. After 
a tew days a more liberal diet may be allowed, as in sub- 
acute and chronic eczema. 

In subacute and chronic eczema meat should be taken but 
once :i day, and should be beef, mutton, or chicken, and 
these should be eaten in the middle of the day when pos- 

1 Materia Medica and Therapeutics of the Skin. Wm. Wood & Co., 
N. Y., 1881. 



ECZEMA. 195 

sible. Breakfast and supper should be very simple, of 
crackers and milk, bread and milk, or some of the grains 
well cooked and eaten without sugar. There is a popular 
idea that oatmeal is injurious. It is best to forbid its use. 
Fish may be allowed, but not those with dark meat or oily. 
An occasional egg may be eaten in the morning, but not 
every day. No pastry, cake, or confectionery should be 
allowed. Apart from absolute simplicity, the patient's 
taste may be consulted, care being taken to avoid anything 
that he knows will disagree with him. It is a good rule 
to tell the patient that he may eat what he likes, but not 
of more than three dishes at a meal. It is unlikely that 
he will then overeat. Those who eat too little for any 
reason should be directed to take that little more often 
during the day. Butter may be taken freely. The dys- 
peptic should drink a cup of hot water about a half-hour 
before meals. It is sometimes necessary for a time to re- 
sort to kumyss or matzoon, and artificially digested food, 
but the sooner he can return with comfort to a more nat- 
ural diet the better. Fried and warmed-up meats should 
be avoided in all cases. Fruits fully ripe or stewed can 
as a rule be liberally partaken of. 

All alcoholic drinks must be absolutely forbidden. Malt 
liquors are especially obnoxious to all irritable skins. Tea, 
coffee, and chocolate are best let alone. Coffee, one small 
cup, may be allowed for breakfast ; or cocoa, which is bet- 
ter, if made with a good deal of milk. Milk, if it does not 
constipate, may be allowed, but not with the regular meals. 
Water should be drunk regularly, and it is not unlikely 
that much of the benefit derived from visiting foreign spas 
is on account of the regular drinking of water. A good 
rule is for the patient to drink a glass of water before 
meals, while dressing, a glass of water or other fluid at 
each meal, a glass of water about two hours after meals 
and before going to bed. If preferred, bottled table 
waters may be used. Vichy water may be substituted 
for plain water once or twice a day. Tobacco is harmful 
in some cases. 

Enforcement of these dietary laws will in many cases 
overcome constipation. It is best not to resort to medicines 



196 DISEASES OF THE SKIN. 

to procure a good daily movement of the bowels, if it can 
be avoided. Kneading of the bowels when in a recumbent 
position will often stand us in good stead, the bowels 
being steadily and deeply rubbed with the heel of the hand, 
starting in the right groin, and following the course of the 
large intestine upward, across, and downward. The habit 
of going to stool at a regular hour of the day should be 
formed, and it should be seen to that the bowels act 
promptly. If we must needs give medicine, the tablet 
triturates of aloin, belladonna, and mix vomica; the pill 
of iron and aloes ; the extract of cascara sagrada, with or 
without mix vomica, which may be administered in capsules 
or as compressed tablets to avoid the disagreeable taste ; 
Startin's mixture — 

R Magnesii sulphatis, 3 V J~SJ SS ; 20-30 

Ferri sulphatis, 3J ; 3 

Ac. sulphur, dil., ,^ij ; 6 

Syr. pruni virgin., ,|j ; 24 

Aquae, ad ^iv; ad 100 M. 

Sig. A teaspoonful tli rough a tube, after meals. 

or any other serviceable remedy may be given. Hardaway 
recommends the phosphate of sodium, a teaspoonful in hot 
water before breakfast, or three times a day, for lithsemic 
patients who are constipated. This is an excellent laxative 
for children, a little of it being put into their milk, to 
which it gives a hardly noticeable salty taste. 

Exercise in the open air is as necessary for eczematous 
patients as for any other class. It should not be taken 
so as to cause over-fatigue. Patients with eczema on the 
face and hands, or with a tendency thereto, should always 
wear gloves during the cold seasons, and should always 
protect the skin of the face by a little powder, calamine 
lotion, or cold cream before going out into the cold, or 
storm of wind or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic has come down from 
old with a reputation for curing eczema, and is largely pre- 
scribed. It had best be let alone. It is only of benefit in 



ECZEMA. 197 

chronic scaling cases, and in only a few of them. It may- 
be used in the form of Fowler's solution (liq. potassii 
arsenitis), giving from two to five minims well diluted, 
three times a day, after meals ; or as arsenious acid, in tablet 
triturates, either with or without pepper, dose ^ to ^ 
grain. The wine of antimony in five-minim doses, three 
times a day, has been warmly commended. Phosphorus, 
TFo to T5 g ram > either in pill or in oil, has been found 
useful in long-standing eczema. Piffard speaks well of 
an infusion of Viola tricolor in acute or chronic eczema 
capitis, especially in lymphatic children. It is made by 
putting one or two drachms of the imported herb into a 
bowl, pouring a pint of hot water over it, and covering 
with a plate. When cool, it is to be taken in divided 
doses during the day. After a few days it generally aggra- 
vates the disease, a good thing to accomplish in chronic 
cases. It is then to be discontinued for a few days or a 
week. In acute cases the dose should be quite small. In 
infants one drop two or three times a day is often suffi- 
cient. Adults may take as much as a teaspoonful in 
chronic, sluggish cases. Turpentine, the spirits, is recom- 
mended by Crocker in obstinate cases. It is given in an 
emulsion with mucilage, three times a day, after meals, 
the dose being ten minims at first, and then, if tolerated, 
increased by five-minim doses up to twenty or thirty minims. 
While it is being taken not less than a quart of barley- 
water should be drunk, and the last dose should be taken 
not later than six o'clock in the evening. The same 
author recommends counter -irritation over the spine, the 
nape of the neck for eczema of the upper half of the body, 
and over the last dorsal and first lumbar vertebrae for the 
lower half. Dry heat, a mustard-leaf, or liquor epispas- 
ticus may be used. I have seen most excellent effects from 
this plan. The spinal ice-bag sometimes accomplishes the 
same result. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by re- 
ducing the congestion of the skin. In chronic eczema, 
even without evident renal derangement, the acetate of 
potash in fifteen-grain doses will prove useful. The itching 



198 DISEASES OF THE SKIN. 

may be so severe in some cases that even our local reme- 
dies may not allay it, and it may seem necessary to give 
some medicine to procure sleep. Never use opium. The 
bromides, chloral, or phenacetine may be given. Hyde and 
Montgomery speak well of calcium chloride in full doses. 
Bulkley recommends tincture of gelsemium, of which ten 
drops are to be given, and repeated and increased every 
half-hour till relief is obtained, or constitutional symptoms 
of languor, tranquillity, dizziness, impairment of vision, 
and drooping of the lids, are produced. Quinine, in 
one-half-grain to fifteen-grain doses, given at bedtime, is 
commended by some for the same purpose. 

Rest in bed is desirable in all severe cases of eczema 
whether they are acute or exacerbations of chronic forms. 

Local Treatment. In all cases, whether due to 
purely local causes or a combination of these and some 
general cause, local treatment is of the greatest importance. 
The books teem with prescriptions which have been found 
efficacious, and some of them contain so many ingredients 
that it is hard to determine with exactness to what the 
benefit is due. After all, the matter is very simple, and, 
if the principles are mastered, little difficulty will be found 
in accomplishing the desired end. In acute cases, where 
we have heat and sivelling, employ soothing remedies; in 
subacute cases, where the sivelling has subsided and where 
the papulation, vesicidation, pustulation, or exudation is 
more or less active, use astringent and protective remedies ; 
in chronic cases, where we have thickening with scaling, 
stimulate ; in all cases protect the shin from external irrita- 
tion. It is better to learn how to use a few remedies and 
to know what to expect from them, than to try every new 
method that appears in the medical press. 

It is a good, broad rule that water should not be used 
on an eczematous skin, as it removes the newly formed 
epidermis and exposes the tender skin to the air. In all 
but chronic cases it should be used sparingly, and only to 
remove dirt, or crusts, or scales, and the skin should be 
at once covered with some protecting powder or ointment. 
If water is used, it should be either rain or boiled water, 
or water with a little soda, one drachm to the basinful, or 



ECZEMA. 199 

bran in it. Often it is better to clean the skin with an 
oily lotion than to use water. 

In acute eczema lime-water, liquor plumbi subacetatis 
dil., lead-and-opium wash, or solutions of borax and soda, 
one or two drachms to the pint, may be sopped on three or 
four times a day, dusted over with cornstarch, compound 
stearate of zinc, dolomol, bismuth, lycopodium, kaolin, or 
French chalk, and covered with light, old linen or muslin. 
All these will allay the itching ; but if this is especially 
severe, the following may be used : 

B Camphori, gss; 3 

Zinci oxidi, ^ij ; 15 

Amyli, j^iv ; ad 30 M. 

Startin recommends the following : 

R Zinci oxidi, Sss ; 6| 

Pulv. calaininse prajp., Qiv ; 2 

Glycerini, £j ; 12 

Liq. calcis, 3vij ; ad lOOj M. 

As soon as the early and most acute stage is passed — 
that is, in the subacute eczema — a protecting and soothing 
ointment is to be used, and of these no one is safer than 
the standard benzoated oxide of zinc ointment that usually 
can be obtained anywhere. The cucumber ointment is 
also soothing. If the case be one in which there is much 
discharge, as in pustular, vesicular, and weeping eczemas, 
Lassar's paste is better than the oxide of zinc ointment, as 
being a paste it allows the discharge to percolate through 
it. It is made as follows : 

R Zinci oxidi, "I -- _... -- «. 

Amyli, } aa 3'J5 aa8 

Vaselini, ^ss ; 16( M. 

The addition of ten to fifteen grains of salicylic acid to the 
ounce increases its antipruritic quality. The only difficulty 
is that it takes time and muscle to make, and but few 
druggists make it well. See that in it, as in all other 
ointments, there are no gritty particles left. All ointments 
must be smooth, or they do harm rather than good. In 



gr. xx ; 


1 


3J; 


3 


3iv; 


12 


3vj ; 


18 


3iv; 


ad 100 



200 DISEASES OF THE SKIN. 

using ointments in eczema they should be evenly spread 
upon cheesecloth folded four times, or upon old washed 
muslin, in a layer as thick as the back of a table-knife 
blade, applied to the affected part and bound down snugly 
with a bandage. They should be changed twice a day, or 
more often if the discharge is profuse. 

Painting a limited moist patch of eczema with a solution 
of nitrate of silver, three to ten grains to the ounce, is often 
a most prompt method of curing the disease. 

Ointments are objectionable on account of their greasi- 
ness, and where possible it is pleasanter to use lotions. 
Of these, one of 

R Calamin., 
Zinci oxid., 
Glycerin., 
Aqiue calcis, 
Aquse rossse, 

answers well. To this may be added carbolic acid in one 
or two per cent, strength, to relieve the itching. Per- 
oxide of hydrogen sopped on exercises a beneficial effect 
on pustulation. 

The diachylon ointment of Hebra will often prove bene- 
ficial, especially after the subsidence of acute symptoms. 
It is best used diluted with ungt. aquse rosse in the propor- 
tion of two parts to one. Most cases that we are called 
upon to treat are in or near to the subacute stage, as the 
acute stage soon passes off. It is always advisable to begin 
treatment not too boldly. If our protecting and astringent 
remedies do not cure the case after a fair trial, then we 
must add stimulants, and of these one of the most reliable 
is tar, adding it at first in the proportion of about fifteen 
drops of the oil of cade to the ounce of ointment-base, such 
as oxide of zinc ointment. 

In chronic squamous eczema we need stimulation to whip 
up the circulation, to produce absorption of the infiltration 
of the skin, and to promote a return to health. Here tar 
is one of our most reliable remedies, and it can be used in 
various strengths and ways. We may use the oil of cade, 
oleum cadini, the oil of birch, oleum rusci, or pix liquida. 



ECZEMA. 201 

There is some doubt and difficulty about obtaining genuine 
oleum rusei, whieli is largely used by tanners in the prep- 
aration <>f Russia leather. The oil of cade is most used. 
Some prefer this ointment : 

Ji 01. cadini, 3ss-j; \ 



Zinci oxidi, 



gss j 



2-41 



Ungnenti aquse rosre ad 5J ; ad 30| M. 

Or the cade may be added to the oxide of zinc ointment 
in the proportion of a drachm to the Ounce. Or pix 
liquida may be substituted in about double the strength. 

Another most excellent way of using tar, and preferable 
to the latter, because not so liable to stain the clothing, is 
that proposed by Pick, namely, to make a strong' tincture 
of tar, using forty parts of pix liquida to twenty parts of 
alcohol; and to paint the part every night with three 
coats of this tincture, letting each coat dry on before 
another is applied. Then cover with oxide of zinc oint- 
ment ; the ointment being changed morning and night. 

Bulkley in some cases recommends tar in what he names 
liquor picis alkalinus, which is made as follows : 



li Picis liquidise, gij ; 25 

Potass, causticae, ^j ; 12 

Aqua 1 , ad §v ; ad 100 



5 
M. 



Dissolve the potash in the water and add slowly to the tar 
in a mortar with friction. This is to be used diluted 
twenty or more times with water, and followed by oxide 
of zinc ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared 
over the body. In some cases the tar will give rise to 
systemic poisoning, the urine will become black, and the 
patient will suffer from headache, oppression, nausea, 
vomiting, and diarrhoea, and the pulse will become fre- 
quent. Of course, under these circumstances the tar must 
be stopped. 

Sulphur is, next to tar, one of our best stimulating 
remedies in squamous eczema. It is not so reliable, as it 



202 DISEASES OF THE SKIN. 

is more uncertain in its effects. It finds its best use in 
circumscribed patches, and may be used in vaseline or 
simple ointment in the strength of one or two drachms to 
the ounce. In some skins it produces a good deal of 
dermatitis. 

Green soap is often of the greatest service in chronic 
eczema. It is to be used in the following way : Take 
either the green soap or Bagoe's prepared olive soap; warm 
water ; and oxide of zinc ointment spread on muslin or 
linen. Dip a piece of flannel in the soap and then in the 
water, and then with it scrub the parts vigorously until all 
the scales are removed and the skin looks somewhat raw. 
Now wash off all the soap with plenty of water, dab the 
part dry with a soft towel, immediately cover with the 
ointment, and apply a bandage. The soap is to be used 
once a day and the ointment changed twice a day. 

Canst ie potash, fifteen grains to one drachm to the ounce; 
or salicylic acid, ten to twenty per cent., in ether, may be 
used to reduce very much thickened patches. Nitrate of 
silver, ten to fifteen grains to the ounce, may also be used ; 
as well as salicylic add, ten to twenty per cent., and chry- 
sarohin, ten per cent. 

Unguent, hydrarg. ammonlat. is of use in chronic ec- 
zema of limited area. 

Ichthyol and resordn are two of the more recent addi- 
tions to our armamentarium. The former has a more 
disagreeable odor than tar, and as Crocker says of it : 
" We do not want more of such remedies, as tar fills that 
place so well ; what is required are remedies which do not 
stain nor smell." In chronic, thickened eczema a forty to 
fifty per cent, aqueous solution well rubbed in once a day 
with a stencil or stiff' paint brush acts admirably. Resor- 
dn in from two to five per cent, strength is a good stimu- 
lating application. 

For the reduction of infiltration and removing the scales 
in a chronic eczema nothing is better for a time than sheet 
rubber applied to the part and bound down with a roller 
bandage. The rubber should be removed once a day, 
sponged off with soda and water, and reapplied. The re- 
lief to the itching procured by this means is sometimes 



ECZEMA. 203 

surprising. As soon as the infiltration is reduced we 
should resort to our tar remedies for completion of the 
cure. 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin dis- 
eases. Thus we have the plaster mulls of Unna, in which 
a plaster mass is incorporated with the mulls. Many 
speak loudly in their praise. Then collodion and traumat- 
icin have been used, and answer well, the tar, salicylic 
acid, or what not, being dissolved or held in suspension. 
In this way chrysarobin may be used on limited patches 
of chronic eczema. Gelatin preparations are very valu- 
able, and applied either to a subacute or chronic patch, 
especially when there is no moisture, will allay the itch- 
ing and hasten the cure. Unna's gelatin paste sets at 
once. It is composed of 

R Zinci oxidi, 30. 

Gelatini, 30. 

Glycerini, 39. 

Aquse, 10. M. 

It forms a hard mass that must be melted before it is 
used. The best way to use it is to put it in a small tin 
saucepan that fits into another pan that holds water, such 
as is used for sterilizing milk or cooking oatmeal gruel. 
This can be heated over a Bunsen burner or spirit lamp. 
When melted and still warm, it is to be painted over the 
part under treatment by means of a wide paint brush. 
Immediately over it place a layer of absorbent cotton, and 
over all a roller bandage. This dressing may be left on 
for two or three days. The gelatin may be used as an 
excipient. Gelanthwn is an ointment base that does not 
contain lard or oil and is a good excipient. Medicated 
soaps have their advocates. I have had no experience 
with the last. 

In the treatment of eczema we must not content our- 
selves by simply giving our patient an ointment, but we 
must instruct him in the way he should use it. As a 
rule, and where possible, ointments should not be smeared 
on the skin, but spread on old linen, muslin, or the like, 



204 DISEASES OF THE SKIN. 

and bound down with a bandage or with a ring of elastic 
webbing. In chronic patches it is well to rub in the tar 
or other ointment. 

Massage sometimes does good service in reducing infil- 
tration, the part being stroked upward, in the course of the 
circulation. 

Baths are not usually advisable in eczema, and are ap- 
plicable only to chronic cases. Good results have been 
reported from some sulphur baths. Residence at the sea- 
side generally proves bad for eczematous patients, but it 
may be a good thing for some run-down patients, the tonic 
eifect of the sea air out-balancing the evil effect of the 
dampness. Soda, borax, or bran baths will prove grateful 
in some cases. Bulkley orders the following : 

R Potass, carbonat, oiv; 130 

Sodii carbonat., oiij; 100 

Boracis pulveris, §ij; 70 M. 

Add to thirty-gallon bath with half a pound of starch. 

Prognosis. We can give assurance of curing eczema 
so far as the attack with which the patient comes to us is 
concerned. We can give no positive assurance that the 
disease will not return. The cure of the attack requires 
patience, careful study of the case, and the intelligent use 
of remedies. But there are some cases that are exceed- 
ingly rebellious. We have to accept the fact that some 
people are " eczematous," and that they cannot be perma- 
nently cured unless they are regenerated. We should cure 
our cases as rapidly as possible, and not take refuge in the 
excuse of the incompetent man and tell the patient that it 
is dangerous to cure eczema. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with Assuring. It may also be moist. 
It usually extends up the whole internatal fold. It gives 
rise to great pain in defecation and to much itching at all 
times. The discharge from this form, as well as from 
eczema of the genitals, is frequently offensive, owing to 
the decomposition of the sebaceous secretions. Excessive 
use of tobacco predisposes to this variety of eczema, prob- 



ECZEMA. 205 

ably on account of the nervous irritation inducing itching, 
for the relief of which the patient scratches and produces 
the eczema. Other predisposing causes are all those that 
cause pruritus ani, which see. 

In treatment the first thing is to stop the use of tobacco, 
a hard task, as the patient is ofttimes incredulous of its 
efficacy. Horseback riding and much walking will some- 
times have to be stopped, as they may aggravate the 
trouble. If hemorrhoids or fissures of the mucous mem- 
brane are present, as they quite frequently are, they must 
be cured in order to obtain a permanent cure of the 
eczema. The bowels must be kept easy by laxatives, so 
that one soft movement may be had each day. Liver 
derangements must be corrected to prevent portal conges- 
tion, and dieting will be of service. The nates must be 
separated by folds of lint, and the parts kept scrupulously 
clean, though water should be used as sparingly as possi- 
ble. The itching may be relieved by sopping on hot 
water, dabbing the part dry, and making the chosen appli- 
cation. Tar or diachylon ointment may be used cov- 
ered with a dusting powder. Usually the drier the parts 
can be kept and the less ointment is used the better. 
Painting a limited surface with salicylic acid, ten to fifteen 
grains in an ounce of flexible collodion, is often followed 
by the happiest results. Painting with nitrate of silver, 
ten to fifteen grains to the ounce, is sometimes advisable. 
Here, too, if there is much thickening, wearing rubber 
cloth for a few days or using a salicylic acid plaster will 
greatly hasten the cure. A well-applied T-bandage is the 
best way of keeping the dressings in place. 

HJczema Annum. Eczema may affect both the ear 
itself and the inside of the auditory canal. When the ear 
is acutely affected, it is swollen at times so much as to 
stand out from the head. In acute eczema of the external 
auditory canal, which is secondary to that of the auricle, 
the swelling may be so great as to cause dulness if not loss 
of hearing. Of eczema of the outer part of the ear noth- 
ing special need be said excepting that the dressings must 
be exactly applied to all the little furrows of the ear, and 
a pledget of lint placed in the furrow behind the ear, thus 



206 DISEASES OF THE SKIN. 

separating it from the side of the head, so that in sleeping 
the two surfaces of skin do not come in contact. Paint- 
ing this part of the ear with a solution of nitrate of silver, 
ten grains to the ounce, will sometimes aid greatly in con- 
verting a moist eczema into a squamous one. A cure will 
be hastened by having the ear covered with a linen bag 
made in the fashion of an ear-muff. Eczema of the 
auditory canal is sometimes very annoying on account 
of an accumulation of scales, dulling the hearing. For 
this condition an ointment of tannin, one drachm to 
the ounce, or a solution of nitrate of silver, five to twenty 
grains to the ounce, may be applied thoroughly by means 
of absorbent cotton on a probe, the ear being properly 
lighted by means of a head-mirror, and the operator 
having the requisite skill. Otherwise the tannic acid 
ointment, or one of oxide of zinc, or the diachylon oint- 
ment may be applied on pledgets of lint rolled up to 
fit the orifice. It must be remembered that ointments 
mixed with the exfoliated epidermis of the canal, and 
forming a paste with it, tend to stop up the canal and 
produce deafness. Such deafness can be removed by 
syringing, or mopping with oiled cotton. The insufflation 
of boric acid will sometimes be better yet. The ear 
should not be syringed out often, and when it is necessary 
to do so a solution of borax or baking soda should be used. 

Eczema Barbce is scarcely ever confined to the bearded 
portion of the face, but it generally runs over onto the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has eczema 
capitis. It needs to be diagnosticated from ringworm and 
sycosis, which see. In treatment, shaving, or cutting the 
hair close, which is better, should be practised so that 
remedies may be closely applied. Plucking the hair from 
the pustules is to be recommended. Its further treatment 
is the same as that of eczema capitis. It is an obstinate 
form of eczema, prone to relapses. 

Eczema Capitis The scalp is very commonly the 
seat of eczema, either by itself or in connection with 
eczema elsewhere. It has received various names, such 
as crusta lactea ; porrigo ; melitagra ; scalled head ; milk 



ECZEMA. 207 

crust; or vesicular or running scall. While any vari- 
ety of eczema may occur on the scalp, the vesicular is 
very rarely seen, and the most common is the pustular, 
and the final stage the squamous. In the acute stage 
the scalp may be swollen and boggy, and moist, with the 
hair stuck together. We may find the scalp crusted with 
a yellowish serous crust, but more commonly there is a 
greenish or blackish purulent crust, while the scalp is 
swollen but little. In some cases of pustular eczema 
there will be discrete, rather large pustules scattered 
through the hair, besides moist and crusted patches. The 
hair is always matted together, and the odor from the 
scalp is unpleasant. If the crusts are removed, they will 
soon reform. 

In both the erythematous and the squamous forms the 
scalp is red and scaly. In the latter variety there is apt 
to be more or less thickening of the scalp, and in very 
severe cases the scalp may be cracked. Not infrequently 
there will be squamous patches in some places and moist 
and crusted patches in other places. 

With eczema of the scalp there is almost always eczema 
behind the ears. The cervical glands are very often swol- 
len, especially in children, but they need give no anxiety, 
as they very rarely suppurate. In the chronic form there 
may be loss of hair, especially in children, when it is 
sometimes mechanically rubbed off from the occiput. It 
is never permanently lost. All forms are itchy, the 
pustular form least so. The patient may complain of a 
" drawn " feeling of the scalp. As in all inflammatory 
diseases of the scalp, there is over-activity of the seba- 
ceous glands, and the crusts will contain a certain 
amount of fat. In chronic cases there may be, on the 
other hand, a deficiency of fat. Pediculi are often found 
on the hair. The disease may affect the whole scalp or 
only a portion of it, and may run an acute or chronic 
course. 

Etiology. The exciting causes of eczema capitis are 
all irritants to the scalp. Sometimes it is well-meant but 
badly directed efforts at cleanliness, especially in children. 
Combing with a fine-toothed comb, too vigorous use of 



208 DISEASES OF THE SKIN. 

soap and water, the use of a too stiff brush, are some of 
these. Pediculi are very often the cause — not the pediculi 
themselves, but the scratching to relieve the itching pro- 
duced by them. An eczema of the occiput should always 
suggest their presence, and search then will generally 
reveal the pediculi or their nits upon the hair. Some- 
times remedies used to kill the lice will set up an eczema, 
such as strong mercurial ointments. In most cases eczema 
of the scalp is but a part of a more or less general eczema 
and due to the same causes. 

Diagnosis. The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythemato- 
sus, a dermatitis, psoriasis, seborrhoea, favus, pediculosis, 
and syphilis. See under these diseases. 

Treatment. The treatment of eczema capitis is along 
the same lines as is that of the disease in general. On 
the scalp it is always best to use our remedies either in 
vaseline or oil, as preparations of lard make a disagreeable 
mess with the hair. Nor should a thick ointment ever be 
used, excepting perhaps in children before their hair is 
grown, or on bald heads. If there are crusts on the scalp, 
they must be removed before any local treatment is used. 
This may be done best by soaking them with sweet oil 
containing one or two per cent, of salicylic acid for twelve 
or twenty-four hours, and then washing them away with 
soap and water. Plenty of oil must be used, and it is well 
to tie the head up in a towel over night. A woman's or 
half-grown girl's hair should never be cut in order to treat 
the scalp. In applying remedies to the scalp, after the 
acute stage, they should be rubbed in, and not merely 
smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without one or two per cent, of salicylic 
acid, form a good application. 

In subacute and chronic eczema of the scalp, tar, espe- 
cially the oil of cade, is our most reliable remedy. It 
must be remembered that it can be used much earlier on 
the scalp than elsewhere, and most cases will improve 
under it as soon as the acute stage is passed. It may be 
begun in the strength of twenty drops to the ounce of oil, 



ECZEMA. 209 

and increased to one or two drachms to the ounce. Many- 
people object to the odor of the tar. We can substitute 
for it : 



Or, 



R Hydrarg. amnion., gr. xx ; 51 

Vaselini, ad 3J ; ad 100| 

R Ac. salicylici, gr. xx-xxx ; 5-6| 

01. olivae, ad ,$j ; ad 100| 



The oil of cajuput in five to ten per cent, strength may- 
be tried. Neither of these is as good as tar. 

If the disease is in a chronic condition, shampooing with 
green soap or its tincture, followed by some oily, not very 
stimulating application, will prove curative. In this con- 
nection it is sometimes best to exhibit the tar in an alco- 
holic solution. Resorcin in three to ten per cent, strength 
may be used cautiously in this way. If the scalp is 
cracked and thickened, great and prompt amelioration will 
be secured by having the patient wear a close-fitting cap 
of rubber. 

Eczema Orurum. Eczema of the legs acquires its pecu- 
liarities from the fact that the circulation of the parts is 
less active than it is in the upper portions of the body, on 
account of the action of gravity upon the returning venous 
blood. It usually is seen as an eczema madidans, though 
any form may be present. Varicose veins, either super- 
ficial or deep, predispose to it ; and an eczema arising from 
such a cause is spoken of as varicose eczema. It is ques- 
tionable if such a condition should not be called varicose 
dermatitis. It is attended with swelling and often great 
oedema. It is located principally on the lower part of the 
leg, and is often complicated by ulceration. Pigmentation 
of more or less dark-brown color follows or accompanies 
it, if of any ohronicity, and occasionally purpuric spots 
will be scattered about the chronic patch. As to treatment, 
nothing special need be said except that it is always advis- 
able to have the legs bandaged snugly from the toes to the 
knee, and that the best result will be attained when the 
bandaging is done by the doctor or a trained nurse. 

Eczema Genitalium often causes a great deal of discom- 
14 



210 DISEASES OF THE SKIN. 

fort on account of the excessive itching that accompanies 
it. It affects the scrotum most commonly, which in some 
cases will be greatly thickened and feel like leather. The 
skin of the penis also suffers at times as well as the glans. 
In women, both the lesser and the greater lips of the vulva, 
as well as the entrance to the vagina, may be affected, and 
show excoriations and thickening. All forms of eczema 
may be encountered in the genital region. In chronic 
eczema of the penis the organ becomes greatly enlarged 
both laterally and longitudinally, on account of the thick- 
ening of the skin. The disease may be confined to the 
genitals, or extend to the thighs or the anal region. The 
presence of diabetes should always be suspected in a case 
of this kind, and the urine should be examined for 
sugar. Leucorrhoea is a common cause of the disease 
in women. 

Treatment. In the treatment of eczema of the geni- 
tals, apart from that appropriate to general conditions, and 
specially to diabetes, it is essential that men should wear a 
well-fitting suspensory bandage, inside of which the dress- 
ing may be placed. The itching may be greatly relieved 
in all forms by directing the patient to sit over a vessel 
containing hot water and to sop the water up on the parts. 
In subacute eczema the skin should be mopped dry, the 
oxide of zinc ointment, diachylon ointment, or Lassar's 
paste immediately applied, and the suspensory bandage 
adjusted. Carbolic acid, one or two drachms to the ounce 
of glycerin and water, may also be used, lightly dabbed on, 
for the purpose of allaying the itching. It should be 
followed by either of the above ointments. For chronic, 
thickened eczema, wearing sheet rubber inside of the sus- 
pensory bandage will give positive and immediate relief, 
and greatly reduce the thickening. After a few days it is 
well to follow it with a tar or resorcin ointment. The use 
of the tincture of tar, as spoken of under chronic eczema 
(page 201), is often most serviceable. In some cases noth- 
ing will do so well as the application of the nitrate of 
silver solution, already given. The spirit of nitrous ether 
may be used as an excipient of this. Hardaway speaks 
highly of rubbing the scrotum with a solution of salicylic 



ECZEMA. 211 

acid in alcohol, one drachm to the ounce, and following 
this with a boric acid or diachylon ointment. 

Women should use a T-bandage instead of a suspensory. 
Otherwise the treatment is the same. In them I have seen 
the nitrate of silver treatment do remarkably well. 

Eczema Intertrigo occurs wherever folds of skin come in 
contact. It usually follows a simple intertrigo, differing 
from it in having a discharge that stiffens linen, and in its 
pruritus. In its treatment the parts should be kept separ- 
ated and as dry as possible by means of a dusting powder, 
or by placing a piece of old linen or cheesecloth between 
the apposed folds of skin. For a dusting powder we may 
use cornstarch either alone or with bismuth or zinc oxide ; 
lycopodium is also an excellent powder ; but the best 
powder of all is the compound stearate of zinc. Kaposi 
has seen gangrenous and diphtheritic inflammation begin 
in an intertriginous eczema. As a rule, these cases do best 
without ointments. This does not apply to eczema inter- 
trigo of the crotch. Here it is well to cover the parts with 
a greasy application, so as to protect them from the action 
of the urine. A dilute diachylon ointment often answers 
admirably. 

Eczema Labiorum is usually due to a nasal catarrh, and 
can be cured only when the cause is removed. Eczema 
may occur about the mouth in an orbicular manner. 
Many people suffer from chapped lips, especially in 
winter. This is an eczema of the vermilion border. For 
this little can be done except to caution the patient against 
moistening the lips. Greasing the lips every night with 
camphor-ice or the like keeps them in good condition. 
Glycerin agrees well with some skins, and is harmful to 
others. The lip may be painted with compound tincture 
of benzoin. 

Eczema Mammarum et Mammillarum. One of the most 
annoying accidents to befall a nursing woman is eczema 
of the nipples. They become excoriated and fissured, the 
cracks sometimes extending to the base of the nipple. 
At times a drop of pus can be squeezed from the bottom 
of the crack. They are exquisitely sensitive, and every 
time the baby takes hold the woman suffers agony. The 



212 DISEASES OF THE SKIN. 

moisture from the child's mouth and the decomposing 
milk left on the nipple aggravate the trouble. Mastitis 
may complicate matters. In the intervals of nursing the 
nipple scabs over. Either one or both nipples may be 
affected. The disease may extend onto the breasts, or 
the breasts may be affected independently of the nipples. 
Women with pendulous and heavy breasts frequently 
suffer with a moist eczema in the sulcus beneath them. 
Apart from this, nothing special need be said about eczema 
of the breasts. There is one disease of the breasts, called 
Paget's disease of the nipple, which at first very closely 
resembles eczema, and it is a question whether it is car- 
cinomatous all the way through, or an eczema develop- 
ing into a carcinoma. (See Paget's disease, for diag- 
nosis.) 

Tee atm ext. It is often possible to cure eczema of 
the nipples even while the child nurses. Sometimes it 
will be necessary to wean the child. Women during the 
latter months of pregnancy should handle their nipples 
every day and bathe them with whiskey or alcohol, to 
which may be added twenty or thirty grains of borax to 
the ounce. This will do much to prevent future trouble. 
The suckling having begun, the nipples should be carefully 
washed off and dried with a soft handkerchief after each 
nursing, and dressed with oxide of zinc or diachylon oint- 
ment should eczema show itself. Of course, the ointment 
should be removed before the infant is put to the breast, 
and this should be done with as little water and as much 
gentleness as possible. If there are cracks, the child 
should nurse through a rubber nipple, and when it lets go 
the nipple should be dried and painted with compound 
tincture of benzoin, or the solution of nitrate of silver 
already spoken of. It is also advised to touch the cracks 
with the nitrate of silver stick. This is very painful, 
and of little use as long as the infiltration of the nipple 
that causes them continues. The nipples may be washed 
with a borax solution and covered with an ointment of 
borax. It is always advisable to use nothing that is 
poisonous in the dressings. Hardaway recommends the 
following for eczema under the breasts: 



ECZEMA. 213 

K Thymol., gr.j; (065 

Pulv. zinci oleat., ^j ; 32| M. 

Eczema Manuum. Eczema of the hands has been called 
" washerwoman's itch," " grocer's itch," " bricklayer's 
itch," and various other itches. It is in many cases a 
trade eczema, caused by strong alkaline soaps, or contact 
with sugar, mortar, or other irritant, such as bichloride 
solutions, formalin, and the like. It may arise inde- 
pendently of any of these trade causes, or it may be part 
of a general eczema. The acute forms, as they occur upon 
the back of the hands, do not differ from the same on 
other parts of the body, and the same may be said of the 
chronic forms. The palms are seldom primarily affected, 
but secondarily to eczema of the wrists or fingers. The 
epidermis of the palms, as well as that of the palmar sur- 
faces of the fingers, is thicker than that of the other parts 
of the body, excepting the soles of the feet, and so the 
vesicles do not rupture readily, but are seen like little, 
more or less translucent grains under the skin. When 
they rupture, the skin is left more or less ragged and 
worm-eaten. The skin over all the joints is liable to 
crack and form painful fissures. Chronic eczema of the 
palms prevents free movement of them on account of the 
thickening and the painful cracking. The skin is red- 
dened and covered with large adherent scales. Itching 
is intense at times. The whole palm may be affected, or 
the disease may form limited areas, as upon the center of 
the palm, over the thenar eminence, and upon the finger- 
ends. This form of eczema is often difficult of diagnosis 
from the squamous syphilide. The occurrence of the 
lesions upon one hand alone should arouse suspicion of 
syphilis, especially if little or no itching is complained of. 

Treatment. Eczema of the palms is one of the most 
obstinate of eczemas to treat when of chronic form, and 
requires active stimulation by means of tar; salicylic acid; 
the soap and salve treatment ; rubbing in five to ten per 
cent, of the oleate of mercury ; or painting with caustic 
potash. The constant wearing of rubber gloves is excel- 
lent for the purpose of softening the skin and preparing 



214 DISEASES OF THE SKIN. 

it for other remedies. It is best to buy the canvas-lined 
gloves, turn them inside out, and wear the rubber next 
the skin. The hands must be kept out of water. Where 
this cannot be done, great care must be used in drying 
them. It is well to have the patient dry on two towels or 
before the fire, and then either to thrust the hands in a 
box of cornstarch powder or flour, or preferably to apply 
the proper dressings. Eczema of the back of the hands 
is treated the same as an eczema elsewhere. Unna teaches 
that eczema of the hands and lingers is always secondary 
to eczema seborrhoicum capitis. He recommends in the 
disease, as it affects cooks, housemaids, and the like, that 
the hands, on going to bed, should be washed with green 
soap and water when the eczema is of squamous form, 
and with a weaker soap when it is moist. Then a 
paste of 

Oxide of zinc, 40 parts. 

Chalk "J 



Lead- water, 
Linseed oil, 



or one of 



Oxide of zinc,' 
Sulphur, 
Chalk, 
Linseed oil, 
Lime-water, 



aa 20 parts. 



is to be well rubbed in. Before using the paste, when the 
eczema is moist the patch should be powdered with flour. 
The paste is covered with the thinnest rubber tissue, such 
as is used for bouquet handles. This will stick well. 
Cotton gloves can be worn at night. In the morning the 
dressing is not to be removed until the roughest part of 
the work is done. Then it is to be washed off, and a little 
of the paste applied until time for the evening dressing. 

In eczema of the hands of masons, washerwomen, and 
the like, an endeavor must be made to thicken the corneous 
layer of the skin by dressing them at night with a paste of 

Resorcin., j aa 10 parts. 

Ungt. zinci oxid., J 

Terraj siliae, 2 " 



ECZEMA. 215 

and applying oil or vaseline over it. In the morning the 
hands are not to be washed, but anointed with some oil. 
After a time the corneous layer thickens and the old skin 
falls off. Eczema of the hands due to occupation becomes 
rapidly well when the patient no longer follows his trade. 
It is sometimes necessary to seek some other occupation. 
Hospital nurses are often much troubled in this way, and 
have to give up nursing. 

Eczema Narium is often, if not always, associated with a 
chronic rhinitis. It is very obstinate. Crusts form on the 
inside of the nose, are picked off, re-form, and after a time 
ulcers result from the constant irritation. Sometimes in 
adults the disease locates itself about the hair follicles, and 
is very annoying. It is a not uncommon point of depart- 
ure for recurrent attacks of facial erysipelas. If long 
continued, it gives rise to a thickening of the upper lip. 
Furuncles sometimes complicate matters. 

In the treatment of these cases the first attention must be 
given to the cure of the rhinitis. Then all crusts must be 
removed by soaking with oil. For the eczema we may 
use : 

R Glycerol, plumbi subacetat., \ — 

Ungt. aquae rosse, J aa p. . -^ 

as recommended by Hardaway. 

Herzog 1 recommends the yellow oxide of mercury oint- 
ment, or equal parts of ungt. plumbi and vaseline, spread 
on lint and accurately applied to the diseased part. Unna 
rolls his zinc and red precipitate ointment muslin into a 
pledget and introduces it into the nose. In obstinate cases 
about the hairs epilation by electrolysis may have to be 
performed. 

Eczema Palpebrarum is usually of an erythematous 
character, and occurs as part of the same disease elsewhere. 
Eczema of the cilise, also called blepharitis ciliaris, is 
always pustular. The edges of the lids are swollen, rounded, 
and more or less thickly strewn with pustules or crusts. 
The lids stick together on waking in the morning. In the 
squamous form the edges of the lids are merely red and 
1 Arch. f. Kinderheilkunde, 1887, p. 211. 



216 DISEASES OF THE SKIN. 



scaly. It is almost always symmetrical, occurs usually in 
strumous subjects, and is due to conjunctivitis. 

Treatment. The lids should be anointed before going 
to sleep, in order to prevent their sticking together. I 
have always found the following ointment, as given by my 
friend, Prof. D. Webster, of the New York Polyclinic, 
most excellent : 

R Ac. salicylici, gr. x ; 8 

Ungt. hydrarg. oxid. rubra, 3j ; 5 

Ungt. aquae rosse, ^vj ; ad 30 M. 

An ointment composed of 

R Hydrarg. oxid. flav., gr. ij-viij ; 0113-5 

Vaselini, 5J ; ad 32] M. 

is recommended by Hardaway. Resorcin, gr. iij in cold 
cream, 3ijss, is editorially commended in the Monats- 
heftef. prakt. DermaL, 1888, vii., 1057. Whatever is used, 
we must be sure that any substance entering into it is in 
an impalpable powder, so as to avoid the possibility of 
getting anything gritty into the eye. Epilation may be 
necessary in some cases. Solutions of bichloride of mer- 
cury (0.05 : 500) are commended, both for the conjuncti- 
vitis and the eczema dependent upon it, In any event, 
the conjunctivitis must be treated. 

Eczema Pedum. Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The greatest 
difficulty will be encountered in dressing the toes properly. 
For this the ointment should be spread upon a long and 
narrow strip of lint, the center of the strip placed against 
the big toe, and the strip wound in and out between the 
toes. A piece of salve-muslin may be substituted for this 
with advantage. A piece of rubber sheeting cut to fit the 
sole and bound down with a bandage takes the place of 
the rubber glove. 

Eczema Unguium. Eczema may affect the nail-fold 
alone, and the nail may be scarcely diseased ; or the matrix 
and bed may be diseased, when the nail will lose its luster, 



ECZEMA. 217 

and become rough, uneven, striated, and atrophied. Only 
one nail may be diseased, or all of them may be. The nail 
may be depressed in the center and turned up at the end, 
with an accumulation of scales under its free border. 
Usually eczema of the nails occurs as a part of a general 
eczema, but it may occur as an independent disease. The 
fleshy parts about the nails usually present signs of inflam- 
mation, and often of an evident eczema. 

It is best treated by means of cots made of rubber. It 
must be remembered that an ointment can never be used 
when rubber is, as the grease rots it. If the time has come 
for an ointment, linen or leather cots must be substituted 
for the rubber ones. The ointment to be used will depend 
upon the condition of the skin about the nails. Strapping 
the nails with a ten per cent, salicylic acid plaster is often 
most satisfactory. 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety, 
with a tendency to cracking in the skin creases of the 
joints, exudation, scaling, and itching. These symptoms 
will serve to distinguish it from dermatitis exfoliativa, to 
which it bears a strong resemblance. Constitutional dis- 
turbances, such as fever and chills, loss of appetite, and 
digestive disorders, are not uncommon in these truly piti- 
able cases. Furunculosis is apt to complicate matters. 
The patients are slow in recovering, and are apt to be a 
good deal pulled down by the disease. 

Teeatment. These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaseline. 
The ordinary Carron oil, equal parts of linseed oil and 
lime-water ; cotton-seed oil with carbolic acid, 1 part of 
acid to 60 of oil; or simply smearing the body with 
vaseline and powdering on cornstarch, will each relieve. 
Salicylic acid in oil, 1 in 30, will also allay the discomfort, 
but it sometimes causes symptoms of constitutional pois- 
oning, and has to be stopped. Alkaline baths, warm, fol- 
lowed by one of the above, after tapping the skin gently 
dry, will also relieve, but the bath should not be used 
more than once a day. Its temperature should be about 



218 DISEASES OF THE SKIN. 

98° F. ; it should last ten or fifteen minutes. Bulkley 
recommends anointing the skin, before drying it, with — 

li Acid, carbolici, 9j _ 3ij ; 1—61 

Glycerit. amvli, ad 3iv ; ad 100[ M. 

applying it freely. The best way of drying the skin is 
to envelop the patient in a warm sheet, and pat the skin 
dry. As the intensity of the eczema lessens, the frequency 
of the baths must be reduced. The disease will gradually 
become localized in patches. 

Eczema Infantile presents certain peculiarities that war- 
rant its being considered as a special variety of eczema. 
It is very prone to be of the pustular form, following the 
rule that in delicate or debilitated subjects an eruption 
upon the skin is apt to be pustular. While in adults 
eczema of the face is usually erythematous, in infants it is 
nearly always pustular. In them it is quite common, if 
not the rule, to have several regions affected at once, such 
as the scalp, the face, and the region of the crotch. In 
them, also, eczema madidans often occurs in these regions. 
While in adults that form of eczema is most frequently 
seen upon the legs, in infants it is quite exceptional there. 
Eczema of the scalp in infants presents itself as a thick 
crust formed of purulent matter, epithelial debris, and 
sebaceous matter. This is called " milk crust." When 
the crust is raised the scalp will be found to be thickened, 
swollen, boggy, and moist, with a purulent secretion. The 
whole scalp may be affected, or only the vertex. With it 
there will nearly always be a moist surface behind the 
ears, even though the face may be comparatively or abso- 
lutely free. The lymphatic glands will be swollen, but 
they seldom suppurate. When the face is affected it will 
sometimes be studded over with holes, superficial ulcera- 
tions, which, however, never leave scars. This appearance 
is seen very rarely in adults. It is often striking to note 
that the skin about the mouth and nose, and below the 
eyes, is in perfect health, though pale, while all the rest 
of the face may be involved in the moist intense inflamma- 
tion. The creases of the neck, the flexures of the joints, 



ECZEMA. 219 

and the region of the genitals usually show an erythematous 
or a moist intertriginous eczema. At times the whole 
body will be affected with a general, but very rarely with 
a universal eczema. While the pustular and intertriginous 
forms of eczema are the most common, we may have all 
forms present at one time. The papular form is also fre- 
quently met with alone. Itching is usually severe, keep- 
ing the little patient awake at night, and the tearing made 
by the nails to relieve the itching gives rise to immense 
excoriations, especially of the face. Unrelieved, the little 
patients sometimes become pitiable objects on account of 
loss of sleep and constant nervous excitement. 

Etiology. There are several causes tending to pro- 
duce eczema in infants. Their skin is vulnerable to all 
irritants. When we consider that the child is born into 
the cold world, suddenly launched out of a warm atmos- 
phere in which it was surrounded by an alkaline fluid, 
covered over with a fatty coating, and safe from the action 
of the atmospheric air, we can but wonder that its skin es- 
capes as well as it does. More than one-third of the cases 
of eczema occurring before the fifth year of life occur in the 
first year. Add to the vulnerability of the skin the over- 
zealous care as to cleanliness commonly bestowed upon it 
for a few months after birth, and we have a good explana- 
tion for its frequence. Bad diet has much to do with its 
production. The vast majority of the little sufferers are 
nursed too often if at the breast, " every time they cry " 
being the rule ; or fed too frequently or improperly," every- 
thing that is going " being again the rule. Inattention to 
the condition of the diapers is another active cause of 
eczema about the genitals. Teething is, without doubt, an 
exciting cause, a fresh outbreak of eczema marking the 
eruption of each tooth. Want of self-control in scratch- 
ing is an aggravating circumstance. The frequent dis- 
turbances of digestion so common at this period of life 
predispose the infant's skin to eczema with rather more 
force than do the same troubles in adults. Fat babies are 
frequent subjects of eczema, especially of the intertrigin- 
ous variety. 

Treatment. The treatment of eczema infantile is 



220 DISEASES OF THE SKIN. 

along the same lines as that of eczema in adults. Special 
stress must be laid upon the feeding of infants, and strict 
rules must be laid down for the parent's guidance. The 
condition of the breast milk must be inquired into, as it 
is often of too poor quality to nourish the child. Women 
will sometimes nurse their children far too long, with the 
idea of preventing conception. If the child is bottle- 
fed, the quality of the milk must be investigated, and 
it as well as the amount regulated. It is very necessary 
to insist upon the child wearing a mask in eczema of the 
face and scalp. This may be made of light flannel or 
muslin, a piece of the stuff being cut somewhat after the 
shape of the face, with holes cut out for the nose, eyes, and 
mouth. A skullcap is to be made, onto which the mask may 
be sewed, or pinned with safety-pins. The ointment is to 
be spread upon lint, cheesecloth, or washed muslin — a strip 
for the forehead, one for the chin, and one for each cheek. 
These are to be laid upon the face, and then the mask put 
over them, fastened to the skullcap, and tied behind the 
head by two strings from its lower corners. It is aston- 
ishing what relief this affords to the itching, and how 
much more rapidly the case improves under it. As it is 
impracticable to use the mask in public practice, Unna's 
paste made of 



Oxide of zinc, 40 parts. 

Chalk, ) 

Lead water, I aa 20 " M. 

Linseed oil, J 



may be used as a substitute. In making, the first two 
ingredients are to be mixed together, and then the last two, 
and then the two parts thus formed. It is to be painted 
on the part, and can not be readily rubbed off, though it 
can be washed off with a little oil. 

The itching of the skin can be relieved by appropriate 
dressings, and it is never necessary to put the child in a 
home-made straight-jacket, by slipping it into a pillow- 
case and sewing up the same between the arms and body. 
This is an extreme measure. In eczema of the crotch 
great care must be given to changing the napkins as soon 



ECZEMA. 221 

as soiled. Fresh, clean ones must be put on, not those 
that have been dried without being washed. Dr. George 
H. Fox has called attention to a tight prepuce as the cause 
of eczema in male children. The urine dribbles away, so 
that a few drops wet the clean diapers, and thus keep up 
the trouble. In such cases judicious stretching of the 
prepuce may obviate the necessity for circumcision. Water 
must be kept from the skin in all acute cases. 

Internally, calomel in tablet triturates, one-tenth grain, 
three times a day for three days, will give good results in 
many cases, even though the bowels are not constipated. 
After an interval of three days the calomel is to be given 
again. Care must be taken not to produce too frequent 
and loose movements of the bowels. The rhubarb and 
soda mixture is excellent in many cases. Other medica- 
tion will be necessary according to the nature of the case. 
Cod-liver oil will often cure a case which has been very 
obstinate. The local treatment is according to the rules 
already given under Eczema. 

Eczema Exfoliativum. See Eczema foliaceum ; Der- 
matitis exfoliativa. 

Eczema Marginatum. See Trichophytosis. 

Eczema Seborrhoicum. Unna published his first paper 
on this subject in 1887. He does not believe that there 
is such a disease as seborrhoea sicca or pityriasis, but that 
both of these, as well as several other recognized forms of 
eczema, are all forms of his seborrheal eczema. Among 
several other articles on the subject, that of Dr. George T. 
Elliot in Morrow's System of Genito-urinary and Skin 
Diseases, vol. hi., stands easily first. It is upon the 
papers of Unna and Elliot that this section is founded. 
The latter proposed the name of dermatitis seborrhoica for 
the disease, which is the preferable title. Unfortunately, 
Unna's title has become the popular name. 

Symptoms. Unna teaches that the starting-point of 
almost all cases of seborrheal eczema is the scalp ; more 
rarely the margin of the eyelids, the axillae, bend of the 
elbows, or cruro-scrotal fold. Upon the head it exists 



222 DISEASES OF THE SKIN. 

mostly as a fine scaling of the scalp that is scarcely notice- 
able at its onset, and it is only after months or years that 
a sudden increase, loss of hair, an unusual amount of scali- 
ness or collection of crusts, severe itching, or, finally, a cir- 
cumscribed moist spot, or an evident eczema, leads the 
patient to consult a physician. The hair during the early 
stage is abnormally dry. A progressive alopecia pityrodes 
may show itself, the scaliness decreasing with the loss of 
the hair to make way for a hyperidrosis oleosa. A 
seborrhoea oleosa may complicate matters, and then we 
find fatty crusts on the scalp. Under these the scalp may 
be pale or slightly reddened. In the majority of cases the 
disease is confined to the scalp. The scaling and crusting 
may increase, a corona seborrhoica may form along the 
hair line, and the affection may extend upon the temples, 
over the ears to the neck, or onto the nose and cheeks. Or 
the catarrhal symptoms may be pronounced, and a moist 
eczema affect the scalp and ears, and, in children, the 
cheeks and forehead. (It will be readily recognized that 
his slightest form is the usually recognized pityriasis, his 
more pronounced form is seborrhoea sicca, and his most 
pronounced form is seborrhoea with dermatitis.) 

From the scalp the disease may spread to other parts of 
the body, sometimes proceeding gradually from above 
downward ; sometimes appearing in places far removed 
from the scalp, the intervening regions being free. Next 
to the head, the sternum is a favorite site for the erup- 
tion, where it most commonly assumes the crusted form, 
and most rarely the moist form. The sternum is affected 
secondarily to the scalp. The crusted form is in round 
or oval spots the size of the finger-nail ; these group and 
partly coalesce, forming patches the size of a silver half- 
dollar, having a scalloped border. The color is yellow, 
with a delicate red border. These may clear up some- 
what in the center and form circles, enclosing a yellowish 
center ; or break and form bow-shaped figures with the 
convexitv outward. The lesions of this form are usually 
covered with a greasy crust. The back is similarly 
affected. (This is Duhring's seborrhoea corporis.) 

In the axillae we meet most commonly with the moist 



ECZEMA. 223 

form, and here it shows a tendency to spread with rapidity 
upon the thorax. From the shoulders it spreads down 
upon the arms almost always in the form of yellowish-red, 
crusted papules, which tend to unite in patches, and also 
to form rings. At times it may look very much like 
psoriasis. It shows a predilection for the flexor surfaces. 
The backs of the hands and fingers are often affected with 
a moist eczema, the trunk and arms escaping. 

Upon the palms and soles we find little heaped-up masses 
of scales corresponding to individual coil glands and re- 
sembling psoriasis guttata. Later the epidermis peels off, 
but there is never any moisture. The crusted form gener- 
ally appears in ring or serpiginous patches on the trunk, 
buttocks, and hips. The cruro-scrotal fold and the ap- 
proximating surfaces of the thigh and scrotum are favorite 
locations for the disease, probably forming here many of 
the so-called cases of eczema marginatum in its dry form 
with festooned margins to the patches, or as an intertrigo 
when it is more moist. The thigh and extensor surface 
of the knee are but little aifected, while the popliteal space 
and the leg often are, either in the large papular or the 
thick-crusted form. 

Upon the bearded portion of the face, when the beard is 
worn, we find either a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and the 
unbearded portions of the face in men we have circum- 
scribed, scaly, yellowish or yellowish-gray, slightly ele- 
vated patches, mostly on the forehead, cheeks, and naso- 
labial fold. There may also be red papules, free from 
scales or with fine yellow ones, with redness of the skin 
between the papules. The face is the favorite location 
for a moist seborrhoeal eczema, in children especially. 
The eyebrows are often involved as well as the eyelids. 
The latter are often swollen, and red, and scaly. The 
vermilion borders of the lips may be aifected, and the lips 
swell, scale, crust, and perhaps crack. The disease may 
attack both the outer parts of the ear and the external 
auditory canal. Scaliness, itching, and great increase of 
cerumen mark the process in the latter situation. 

Etiology. Seborrhoeal eczema occurs at all ages and 



224 DISEASES OF THE SKIN. 

in both sexes, but it is specially prevalent between puberty 
and thirty years of age. Though most of the patients 
with it seem to be in good health, careful inquiry will 
bring out the fact that they either are not in perfect con- 
dition or they are living unhygienic lives. Elliot thinks 
that an in-door life favors the disease. It is in all prob- 
abilitv a parasitic and contagious disease. Barber shops 
doubtless are distributing centers of the malady. It is 
quite impossible to estimate the prevalence of the disease, 
as only the more pronounced cases are seen by the phy- 
sician. 

Pathology. According to Elliot, it is a dermatitis of 
catarrhal nature. He found evidences of inflammatory 
infiltration about the papillary vessels, and the ascending 
branches from the subpapillary plexus, and along the hair 
follicle, even in what is usually regarded as a pityriasis. 
In seborrhcea sicca, so called, the infiltration extended to 
the plexus itself, while in the higher grades the inflam- 
mation involved nearly the entire cutis. The sebaceous 
glands were apparently unchanged, and there were no 
evidences of the incomplete metamorphosis of their cells 
such as is usually described in seborrhoea sicca. Con- 
trary to Unna's observations, he never found any fat in 
the sweat glands or their ducts, though there were evi- 
dences of degeneration of the glands ; nor did he find 
fatty infiltration of the cutis or rete. 

Unna has described a mulberry coccus in this disease 
which he names morococcus. Dr. Merrill 1 has succeeded in 
isolating a diplococcus, in making a pure culture of it, and 
in reproducing the disease by inoculation. If his obser- 
vations are corroborated, we have the evidence that the 
disease is parasitic. 

Diagnosis. Many cases commonly regarded as eczema 
are included by Unna and Elliot in seborrheal eczema or 
dermatitis, as the latter thinks the preferable name. In 
diagnosis stress is laid upon the fact that the disease begins 
upon the scalp and spreads from there downward in a more 
or less capricious manner; upon the more or less absence 
of itching ; upon the superficial charaeier'bf the 'esions, 
'New York Med. Jonrn., 1895, lxii., 528, and 1897, lxv., 322. 



ECZEMA. 225 

their tendency to take on definite forms, their yellowish 
color, and the greasy feeling of the crusts. In all these 
things the disease differs from an eczema. At times 
seborrheal eczema of the body bears so striking a like- 
ness to 'pityriasis rosea that it is hard to differentiate the 
two. Pityriasis rosea does not occur on the scalp ; but as 
seborrheal eczema is of very common occurrence on 
the scalp, and may be found in conjunction with pityriasis 
rosea, this is not of much aid in diagnosis. The rings of 
pityriasis rosea are not so greasy and yellow, have fawn- 
colored, dry centers, and lack the punctate border so often 
seen in seborrheal eczema. Then pityriasis rosea runs a 
rapid and self-limited course, whereas seborrheal eczema 
is chronic. If pityriasis rosea occurs typically upon the 
trunk, there is no difficulty ; but when scaly ring-shaped 
patches occur on the limbs alone a positive diagnosis can 
not be made without a good deal of study. 

The psoriasiform seborrheal eczema differs from psoria- 
sis in occurring in locations not typical of psoriasis, and 
in having a more yellowish cast of color, and more greasy, 
yellowish scales. Many cases can be diagnosticated only 
by taking into consideration the probabilities for and 
against psoriasis. 

Treatment. The best remedy for the moist form is, 
according to Unna, sulphur, and for the scaly and crusted 
forms chrysarobin, pyrogallol, and resorcin. It is always 
necessary to direct special attention to the scalp and eye- 
lids, as these are the foci from which the disease spreads. 
For the disease upon the back of the hand, it is recom- 
mended that the affected parts be covered with a thin 
layer of lint soaked in the following solution diluted one- 
half: S 

Alcohol, dil., 180 " M. 

and over this a large piece of gutta-percha tissue is to be 
bound. This is to be used at night, and during the day 
a zinc-oxide p^So^ with or without tar, sulphur, or resorcin, 
is to be applied. 

15 



226 DISEASES OF THE SKIN. 

In my hands sulphur in some form answers best in 
most of the cases. Elliot commends for the disease, 
specially as it affects the scalp, lotions of resorcin, three 
to ten per cent, in equal parts of alcohol and water, with 
which the parts are to be moistened several times a day. 
The scalp is to be washed with soap and warm water once 
or twice a week. If the lotion is too drying, a resorcin 
ointment of the same strength is to be used once or twice 
a week or on alternate days. He uses sulphur as an after- 
treatment. The resorcin lotion sometimes causes exfolia- 
tion of the scalp. 

Salicylic acid, three to five per cent., in the form of a 
lotion for the scalp, and of an ointment for the body ; and 
the ammoniate of mercury ointment in full strength or 
diluted, are both excellent. Hodara 1 recommends in the 
dry forms of the disease an ointment composed of 

R Chrvsarobin., gr. i ad If 102-1 

Ichthyol., gr. f ad If 04-1 

Yaselin., ad 3iij ; ad 100L M. 

which is to be applied at night and removed with cold 
cream in the morning. If reaction occurs, the ointment 
should not be used until it subsides. On the scalp the 
chrvsarobin may be used in the same strength in alcohol, 
with the addition of a little castor oil. 

Elephantiasis. Synonyms : Barbadoes leg; Cochin-China 
leg ; Glandular disease of Barbadoes ; Sarcocele of the 
Egyptians ; Tropical big-leg ; Bucnemia tropica ; Morbus 
elephas; Pachydermia; Spargosis; Phlegmasia Malabarica ; 
Hernia carnosa ; Elephantiasis Indica seu Arabum. 

A chronic endemic or sporadic disease of the skin, char- 
acterized by hyperplasia of the skin and subcutaneous 
tissues, due to a stoppage of the lymphatic or venous cir- 
culation, especially the former, affecting chiefly the lower 
extremities, and marked by enormous enlargement of the 
affected part. 

Symptoms. In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 

1 Monatshefte f. prakt. Dermat., 1899, xxix., 264. 



ELEPHANTIASIS. 227 

America, the disease is endemic ; but sporadic cases occur 
in all parts of the world. The symptoms of the two forms 
differ only in that in the endemic variety there is usually 
what is called "elephantoid fever," with lumbar pain, 
nausea, and vomiting, and followed by sweating. The 
fever is of high grade, and bears a striking resemblance 
to malarial pyrexia. In sporadic cases the characteristic 

Fig. 22. 




Elephantiasis. (After Taylor.) 

fever is wanting, though usually there is some constitutional 
disturbance preceding the local symptoms. In other in- 
stances the fever is altogether wanting. 

Locally the affected part at first is attacked apparently 
by erysipelas, or a deep dermatitis, phlebitis, or lymphan- 
gitis ; it becomes greatly reddened and swollen ; and there 



228 DISEASES OF THE SKIN. 

may or may not be a clear or milky discharge from the 
skin, and an eruption of vesicles. After a time these 
symptoms subside, but the part does not return to its 
normal size, and there is some pitting of the skin on 
pressure. After a few weeks or months there is a repetition 
of the attack, and the part is left still more enlarged. 
And so the case progresses with varying periods of quies- 
cence, and recurrent erysipelatous attacks, each one leaving 
the part more thickened than before, until it attains enor- 
mous proportions. The normal contour of the part is lost ; 
the folds of the skin are obliterated, the surface is smooth 
and shiny, and the color grows darker, even blackish. 
Now no impression can be made upon the swelling by 
pressure of the finger. Ulcerations are apt to occur, and 
some cases show varicose lymphatics which are tender and 
painful, and may rupture of themselves or by accident and 
discharge a clear or milky chylous, coagulable fluid. The 
escape of this fluid saps the patient's strength. 

The parts most frequently affected are the legs, usually 
one, but may be both ; and next to them, the male or 
female genitals. It occurs also on the arms, face, ears, 
female breast, and tongue. When the leg is the seat of 
the disease it becomes so large as to interfere with locomo- 
tion and compels the sufferer to take to his bed. The 
surface of the limb may be smooth ; or uneven on account 
of the varicose lymphatics ; or warty on account of en- 
largement of the papillae. The foot and leg may melt into 
each other, as it were, all trace of the ankle being lost. 
Wherever there are two surfaces in contact there is apt to 
be a decomposition of the sweat, sebaceous matter, and 
epithelium, giving rise to a foul odor, like, but worse than, 
that of an ordinary intertrigo. The lymphatic glands in 
the groin are enlarged. Eczema may develop with its 
attendant itching. The appearance of this elephantine 
leg gave the name to the disease. When the scrotum is 
the affected part, vomiting often occurs in the febrile at- 
tacks, as well as pain in the groins, along the spermatic 
cord, and in the testicles. Hydrocele may develop, and 
the abdominal rings, overstretched by the swollen cords, 
may give opportunity to the formation of hernia upon the 



ELEPHANTIASIS. 229 

subsidence of the acute symptoms. The scrotum may 
become so large as to reach the ground when the patient 
is standing, and one case has been reported in which it 
weighed one hundred and ten pounds. One form of the 
affection is called "lymph scrotum or nsevoid elephanti- 
asis/' on account of the marked dilatation of the lym- 
phatics. 

There are all degrees of thickening of the skin and 
subcutaneous tissues, but the recurrent attacks of erysipe- 
las and the progressive enlargement are characteristic of 
all. The bones may become enlarged. This is a very 
rare affection, which is called "acromegalia." In the 
Lancet of June 11, 1887, several cases are reported, one 
of which was on exhibition in a travelling show as the 
" Elephant man." In his case the head attained massive 
proportions. 

Etiology. The disease occurs in both sexes and in all 
ages, but is most common in men of middle life and in 
the dark-skinned races. Moncorvo 1 reports a case in an 
infant four months old, and speaks of a case in one fifteen 
days old. He believes that it may develop in utero. 
Floras 2 reports a case beginning at birth and remaining 
stationary for fifteen years, when it assumed the typical 
course of the disease. It is particularly prevalent in damp, 
malarious parts of the seacoast. It is not supposed to be 
hereditary, though in countries in which it is endemic 
several members of the same family may be affected by it. 
Leprosy and elephantiasis have been accidentally asso- 
ciated. Exposure to cold, phlegmasia dolens, cellulitis, 
ulcers, lupus, repeated attacks of eczema or erysipelas, 
posture, as the hanging down of a limb on account of rheu- 
matism, pressure upon veins or lymphatics by tumors, may 
give rise to the disease. In fact, any disease of the skin 
that is attended by repeated inflammatory outbreaks favors 
the occurrence of elephantiasis. The filaria sanguinis 
hominis is said to be the cause of the endemic form of the 
disease. It is not found in every case, and is rarely en- 
countered in sporadic cases. 

1 Eev. mens, des Mai. de l'Enfance, 1886, iv., 101. 

2 Arch. f. klin. Chirurgie, 1888, xxxvii., 598. 



230 DISEASES OF THE SKIN. 

Pathology. Anything that will occlude the lymphatic 
or venous channels may cause the disease. In endemic 
cases it is the ova of the filaria that do this. In sporadic 
cases the several etiological factors play the same part. 
However caused, the result is an enormous hypertrophy 
of the subcutaneous tissue from increase of fibrous tissue 
in various stages of development. The corium is also in- 
creased in thickness, and there is proliferation of the 
epidermis, enlargement of blood vessels, lymphatics, and 
nerves. In advanced cases the muscles undergo fibro-fatty 
changes, and the bones become enlarged. (Crocker.) 

Diagnosis. The recognition of elephantiasis is easy, as 
its symptoms are pronounced. In some cases of syphilis, 
however, an elephantiasic thickening of the foot or feet 
takes place that may be thought to be elephantiasis. In 
it, however, there is an absence of the history of repeated 
inflammatory attacks, the outline of the thickening is rather 
well denned, and old cicatrices or ulcers characteristic of 
syphilis will commonly be found. The condition is one of 
gummatous infiltration with chronic oedema, consequent 
upon obstruction of the lymphatics. 

Treatment. The best thing for a patient with en- 
demic elephantiasis to do is to go to a more healthful 
climate. The treatment of the patient during the exacer- 
bations is purely symptomatic, with fomentations, quinine, 
iron, and the like. Various measures for the cure of the 
disease have been proposed, but none is perfectly satis- 
factory. Of course, the scrotal tumor may be cut off. 
The leg has been amputated at the hip, a dangerous opera- 
tion. Unfortunately, the other leg has become diseased 
soon after the one has been cut off. Ligation of the 
femoral artery has been performed, but the result has not 
been satisfactory. Compression by means of a Martin's 
rubber bandage, or the ordinary roller bandage, will afford 
relief. When it is left off for a time enlargement will 
again take place. It, of course, cannot be used while in- 
flammation is present. Bentley * has reported the cure of 
a case by the inunction of a half-drachm of mercurial 
ointment twice daily, and the application of a firm bandage 
1 Lancet, 187S, i., 785. 



ENDOTHELIOMA. 231 

for fourteen days. After that the inunctions were made 
once a day. Internally he gave iodide of potash alone, or 
in this formula : 



R Potass, iodid., gij ; 1 

Potass, chlor., gj ; 1 

Sol. hydrarg. perchlor., gss; 6 

Inf. chiretta, ad ^viij ; ad 100 

Sig. ^ss (6.5) three times a day. 



5 
5 
M. 



Galvanism has produced alleviation, if not cure, in some 
cases. Hardaway has seen great amelioration in one case 
by the use of Squire's glycerole of the subacetate of lead. 
Massage is beneficial. Stretching or excision of a part of 
the sciatic nerve is spoken of by J. Nevins Hyde as hav- 
ing been followed by amelioration of the condition. 

Prognosis. Unless the patient is exhausted by the 
loss of lymph, the disease may last indefinitely without 
deterioration of the health. 'Death may result from 
pyaemia or thrombosis. The patient often dies from some 
intercurrent affection. 

Elephantiasis G-raeconim. See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture 
of the pulmonary alveoli on account of vomiting or par- 
oxysmal coughing, and the air making its way under the 
skin. The affected part looks swollen, feels cushiony, and 
gives a delicate crackling sound on palpation. There will 
be a history of the sudden occurrence of the swelling after 
coughing or vomiting, and probably more or less dyspnoea 
will be experienced. The air slowly escapes and the parts 
return to their normal condition. 

Endemic Verrugas. See Favus. 

Endothelioma. Under this title E. Spiegler 1 has re- 
ported several cases of tumors that occurred in adult life, 
upon the scalp especially, but also on other regions. They 
were present in great numbers and tended constantly to 
increase in number and in size. They varied in size from 
a pea to an orange. They projected high above the level 
1 Arch. f. Dermat. u. Syph., 1899, 1., 163. 



232 



DISEASES OF THE SKIN. 



of the skin, and were round or flattened. They were firm 
and elastic, and were either covered with smooth adherent 
skin or superficially excoriated or ulcerated. The apposed 
surfaces of neighboring tumors were often deprived of epi- 
dermis, bled slightly, and secreted a sero-purulent, badly 
smelling fluid, which dried into crusts between the tumors. 

Fig. 23. 







Endothelioma (Spiegler). 

In one of the cases the disease had lasted forty years, and 
there was a history of the first tumor having appeared 
after the healing of a cut of the scalp. 

Endurcissement du Tissu Cellulaire. See Sclerema 
neonatorum. 

Engelures. See Dermatitis calorica. 



EPITHEUALKREBS. 233 

Ephelides. See Lentigo. 
Ephidrosis. See Hyperidrosis. 
Ephidrosis Cruenta. See Haematidrosis. 
Ephidrosis Tincta. See Chromidrosis. 

Epidemic Skin Disease of Savill. See Dermatitis epi- 
demica. 

Epidermolysis Bullosa. Synonyms : Acantholysis bullosa 
(Goldscheider and Joseph) ; Dermatitis bullosa (Valen- 
tine). This is a rare disease, or rather peculiarity of the 
skin, in which bullae arise upon the slightest pressure. 
The disease shows itself in infancy, and occurs especially 
upon the hands and feet, but may occur anywhere on the 
body. The tendency to the formation of bullae lessens 
toward middle life. The lesions begin either as a red spot, 
which is itchy, or without precedent redness or other sub- 
jective symptoms. A bulla begins to form shortly after 
the exciting pressure, such as from the shoe in walking, or 
even friction from a suspender, has been received, and 
keeps on enlarging for two or three days. It then grad- 
ually decreases, dries into a crust, which falls, leaving 
healthy skin. If the bulla is broken, it discharges a yel- 
low, slightly sticky fluid, and leaves a suppurating base. 
It may be hemorrhagic. The disease is hereditary in cer- 
tain families, but it may occur independently of this. It 
is most pronounced in summer-time. In most cases hy- 
peridrosis is pronounced. Elliot, 1 from his microscopical 
study of the disease, believes it to be " due in a predis- 
posed individual to an excessive response on the part of 
the blood vessels to an external irritation, and the con- 
sequent pouring out of an enormous amount of serous ex- 
udation." He regards it as an "inflammatory process, 
originating in the cutis itself, and manifesting itself by the 
formation of bullae after slight or severe traumatisms." 
No treatment is of avail. 

Epithelialkrebs. See Epithelioma. 

1 Journ. Cutan. and Gen-Urin. Dis., 1895, xiii., p. 10. 



234 



DISEASES OF THE SKIN. 



Epithelioma. Synonyms : (Fr.) Epitheliome cancroide ; 
(Ger.) Epithelialkrebs ; Cancroid, Skin cancer, Epithelial 
cancer, Noli me tangere, Rodent ulcer. 

Epithelioma is a chronic, progressive, malignant new 
growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard, 
waxy edges, and by a strong tendency to return after ap- 
parent removal by knife or caustic. 

Symptoms. Epithelioma always begins in a most in- 
nocent manner, and may be present for months or years 
before the patient dreams that he has a serious disease. It 
may occur upon the skin alone, or upon the mucous mem- 
brane alone, or upon both the skin and mucous membrane 
at their line of juncture. Epitheliomas occurring upon 
the tongue, larynx, or uterus do not concern us here, as 
they belong to the domain of surgery. The starting- 
point of the disease may be a crack or an abraded scaly 
spot, as on the lip; a small, flat, scaly sebaceous patch; 
a white, pearly looking, hard nodule ; a senile or other 
wart or papilloma ; a pigmentary mole ; a cicatrix ; an 
adenoma ; a chronic or lupous ulcer ; a psoriatic patch, 
or some other new growth in the skin. Some of these 

Fig. 24. 




Epithelioma. 
(From Prof. G. H. Fox's service at the Vanderbilt Clinic.) 



lesions may have been present for many years, as, for in- 
stance, a mole. Some appear but a short time before they 
frankly declare their nature, such as the waxy nodule. 
However it may begin, it will be noted that the previously 



EPITHELIOMA. 235 

existing lesion more or less rapidly becomes more dense, 
and after a varying time ulceration occurs, the disease 
spreads at its edges, and the ulceration grows deeper and 
deeper, eating its way through skin, muscles, and bone in 
the infiltrating form, or creeping over the surface in the 
most superficial form. The lymphatic glands may be in- 
volved early in the course of the disease in the deep forms, 
or not for many years in the superficial forms. Eventually 
they may become swollen, hard, break down, and ulcerate, 
assuming the appearance of an epitheliomatous ulcer. A 
typical epitheliomatous ulcer is irregular in shape, with 
raised, hard, waxy-looking, rounded, or everted edges, over 
which, quite commonly, course dilated blood vessels ; the 
floor is uneven, bleeds easily when touched, and is covered 
by a brownish crust or a sanious, purulent secretion. Epi- 
theliomas are usually single lesions, but they may be multi- 
ple. Some years ago there was a patient in Dr. George 
H. Fox's service at the New York Skin and Cancer Hos- 
pital who had scores of epitheliomas developing from 
large, waxy, reddish nodules scattered all over his face. 
Sometimes a single epithelioma attains vast dimensions, 
involving the whole of one side of the face, scalp, and 
neck in one huge excavated ulcer. Sometimes before the 
characteristic ulceration develops the new growth may 
take the form of a single enlarged papilla or a group of 
them. In some cases it may have a cauliflower-like ap- 
pearance, spreading out from a more or less narrow base. 
Fissures are apt to form between the papillae, and then 
there is usually an offensive discharge. This is called the 
papillary form. 

Subjective symptoms are absent in many cases at first, 
but in the deep, infiltrating form pain of a lancinating 
character is present. This often is so severe that the suf- 
ferer is robbed of his sleep. Sometimes there is no pain, 
and the patient experiences only the discomfort incident 
to the ulceration. Sooner or later in nearly all cases 
lancinating pain is a symptom of the disease. 

The course of the disease is always chronic. Different 
cases show different degrees of malignancy. Some will 
prove fatal in four years or less ; some will last indefi- 



236 DISEASES OF THE SKIN. 

nitely. There is no tendency to recovery, though at 
times a partial attempt at healing will be made. I have 
watched one superficial epithelioma in an old Irish woman, 
in Prof. E. B. Bronson's service at the New York Poly- 
clinic, creep over the skin of the face, healing up in the 
older parts while spreading ahead. She refused active 
interference. While all epitheliomas show a strong ten- 
dency to return after operation and in the scar left by 
it, in some cases this tendency is much more marked than 
in others. 

While epithelioma may occur upon any part of the 
body, it is most frequently located upon the lower lip, 
where it occurs, according to Paget, in fifty per cent, of 
the cases. The next most common location is the face. 
A favorite location upon the face is upon the side of the 
nose and near the inner canthus of the eye. Here it is 
very apt to pass over onto the eyelid and destroy it. Nol 
infrequently it begins upon the eyelid itself. The external 
genital organs of both sexes, and the anal region more 
rarely, are other common sites. The upper lip is very 
rarely affected. 

It is customary to describe a number of forms of epi- 
thelioma, but it seems to me much better, especially for a 
student, not to encumber his mind with too many names. 
The superficial, deep-seated or infiltrated, and the papil- 
lary forms have already been mentioned. The chimncy- 
sirccp's cancer is an epithelioma of the scrotum met with 
in paraffin- workers and chimney-sweeps. The rodent 
ulcer used to be described as a special form of disease, but 
it is now considered to be an epithelioma. Clinically, it 
is supposed to be characterized by occurring on the skin 
of the upper half of the face, by running a slow and pain- 
less course, by not involving the lymphatics, and by per- 
pendicular rather than lateral extension. 

Etiology. The cause of epithelioma is often obscure. 
We know that repeated irritation of a part is often fol- 
lowed by its advent. Smoking short clay pipes is not un- 
commonly followed by epithelioma of the lip ; a ragged 
tooth aceounts for many an epithelioma of the tongue; 
the wearing of spectacles or eye-glasses has in some cases 



EPITHELIOMA. 237 

apparently caused the new growth upon the nose; con- 
stant picking or inadequate attempts at the removal of 
warts and scaly spots would seem to account for epitheli- 
oma of the face ; and the scratching to relieve pruritus 
of the anus may play the same part in producing the 
disease about the anus. This constant irritation would 
explain the appearance of epithelioma in paraffin-workers 
and chimney-sweeps, in chronic ulcers, psoriasis, old cica- 
trices, and the like. A congenital or acquired phimosis 
and the repeated inflammation due to decomposing smegma 
are the forerunners of the disease upon the penis. Age is 
the most pronounced predisposing cause. The disease is 
rare under thirty years of age, and increases in frequency 
beyond that period. One case has been reported by 
Kaposi in the tenth year of life. Heredity has some in- 
fluence, though D. Lewis has found that it is not so well 
marked as it is frequently assumed to be. Males are more 
often affected than females. It seems to have a predilec- 
tion for all neoplastic growths. The theory that it is due 
to a specific parasite, and therefore contagious, is gaining 
ground, but thus far has not been demonstrated. 

Pathology. Crocker sums up the pathology of the 
affection as follows : " The essence of the epitheliomatous 
process is the development of epithelium and its infiltra- 
tion into the deeper tissues where it does not normally 
exist, and where its presence produces irritation and con- 
sequent inflammatory changes." " Cell-nests, consisting 
of horny transformed cells in the center, and of lamina? of 
flattened epithelium externally, are characteristic of the 
disease, but are not present in every case, nor is their 
presence always necessary for a diagnosis." (Robinson.) 
Some epitheliomas begin in the rete as a prolongation 
downward of the interpapillary processes ; some in the epi- 
thelium of the sebaceous or sweat glands, or hair follicles. 

Diagnosis. The disease must be differentiated from 
lupus, syphilis, sarcoma, papilloma, and seborrheal warts. 
From lupus it differs in an entire absence of brownish 
lupus tubercles ; in beginning late in life, as a rule, while 
lupus begins in early life ; by its comparatively more 
rapid course ; its lancinating pain ; the involvement of the 



238 DISEASES OF THE SKIN. 

lymphatic glands ; the deep ulceration ; the waxy, raised, 
hard margin ; and the development of the cancerous 
cachexia. From syphilis it differs in having a single and 
not a multiple lesion ; in its slower course ; in its showing 
no tendency to recovery; in its not responding to internal 
treatment ; in its painfullness ; and in its waxy, raised, 
hard margin. An initial lesion of syphilis on the lip has 
not infrequently been taken for an epithelioma. In it we 
have more rapid growth, more induration, an early en- 
largement of the neighboring lymphatic glands of peculiar 
hardness, and the appearance of secondary eruptions on 
the body, all of which are wanting in an epithelioma. 
Sarcoma usually occurs earlier in life, tends to more rapid 
development with metastases in neighboring or distant 
parts, and either does not ulcerate or ulcerates in a very 
different way than does epithelioma. From papilloma 
and seborrheal warts there are no positive diagnostic 
marks of distinction. Either of the two diseases appear- 
ing late in life or showing symptoms of activity at that 
time should rouse our suspicions. 

Treatment. Complete and radical destruction of the 
disease is the only thing to be done in the treatment of 
epithelioma. As a prophylactic measure, it is well to 
destroy all suspicious warts appearing after middle life, 
and to apply appropriate treatment to seborrheal patches 
occurring at the same period. Superficial caustics should 
never be used to an epithelioma, as they only encourage 
its growth. The radical treatment will differ with the 
point of view, all surgeons inclining to the knife, while 
dermatologists advocate the curette or powerfully destruc- 
tive caustics. If the knife is used, it must cut out a wide 
margin beyond the growth. Extirpation is especially 
applicable, and the most appropriate treatment for epithe- 
lioma of the lip, eyelids, and penis. In the latter the organ 
must be amputated above the ulcer, if that has attained 
any size, and the inguinal glands likewise taken out. In 
all cases in which the lymphatic glands have become 
involved they should be taken out. Therefore when the 
lymphatic glands are involved only excision is to be 
thought of. 



EPITHELIOMA. 239 

To all superficial epitheliomas and to many of the 
infiltrating variety Schwimmer's plan of treatment will be 
applicable, and will prove curative. The growth is to be 
scraped out thoroughly with the dermal curette (Fig. # 25) ; 
the diseased tissues will give way readily ; the bleeding is 
to be stopped by pressure ; and a pyrogallic acid ointment 
of 33^ per cent, strength is to be applied. Care should be 
taken that it be applied exactly to the growth, for though 
it exerts its greatest action upon the diseased tissues, it 
also acts upon the sound skin. This ointment will pro- 
duce a black crust over the growth, on account of oxida- 
tion of the acid, and will cause a free discharge from the 
scraped surface during a few days. The discharge be- 
comes less by degrees. After a week or ten days the 

Fig. 25. 



The dermal curette. 

black crust is to be removed by covering it with carbol- 
ized vaseline for twenty-four or forty-eight hours. Last 
of all, mercurial plaster is to be applied, under which the 
part will heal. This method gives most satisfactory re- 
sults, and is not particularly painful if cocaine is used 
hypodermically before the scraping. Smaller epitheliomata 
can be curetted without using cocaine. After curetting, 
the base should be bored into with a point of nitrate of 
silver. 

Arsenic holds the first place among caustics. Marsden's 
paste, composed of one or two parts of arsenious acid and 
one part of gum acacia, by weight, rubbed together and 
mixed with a twenty to forty per cent, aqueous solution of 
cocaine into a paste of the consistency of butter just before 
using, is perhaps the most often used. It is dreadfully 



240 DISEASES OF THE SKIN. 

painful and often causes great oedema. Before applying an 
arsenical paste, if ulceration has not taken place, the epi- 
thelium should be curetted so as to leave a new surface. 
It should be applied to the affected part on linen, the paste 
overlapping the edge of the tumor by half an inch, and 
left on for twelve to twenty hours, according to the patient's 
endurance and the effect produced. The patient should 
be seen frequently, and the paste removed as soon as a 
greenish or blackish eschar is formed. Poultices are to be 
applied after the paste, and kept on continuously till the 
slough separates, and then simple ointment used. The 
slough may not fall for weeks, and when it does a clean 
surface is exposed that soon completely heals. It is to be 
noted that the use of a strong arsenical paste is much safer 
than a weak application, as it produces so much inflammation 
and destruction of tissue that the arsenic is not absorbed. 
Arsenic is better than some other caustics, as it attacks 
by preference diseased cells and leaves the sound skin 
almost unharmed. If the growth has not been destroyed, 
the process may be repeated. This is the treatment recom- 
mended by A. R. Robinson. 1 D. Lewis 2 has had good 
results from using Bougard's paste, as follows : 

R Wheat flour, \ 
Starch, / 



Arsenic, 1 

Cinnabar, \ _- - 

Sal. ammoniac, J 

Corrosive sublimate, 

Solution of chloride of zinc @ 52°, 245 



50 

M. 



The first six ingredients are separately ground to a fine 
powder and mixed in a mortar. Then the solution of 
zinc is slowly added while the mass is stirred. It is to be 
kept covered in an earthen jar. A portion is to be applied 
accurately to the part and kept on for thirty hours, and 
followed by a poultice. Cocaine, 20 per cent., may be 
added to decrease the pain. Another method of using 
arsenic is known as Cerny's. He uses : 

1 Atlantic Med. and Surg. Journ., 1895-6, xii., 713. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1890, viii., 70. 



EPITHELIOMA. 241 



R Acid, arsenios. pulv., gr. xv ; II 

Alcohol, ethyl, absolut., "I -- „ n J 

Aqu^edestillat, } aap.*. ad!50| 



The solution is to be shaken up and painted over the 
denuded surface of the epithelium, and a new coat laid on 
when the first is dry. It is used daily unless oedema is 
caused, when a pause is made until this subsides. After a 
time an eschar forms and falls. Then apply the solution 
again to the surface, and if only a yellowish crust forms 
that can be removed without bleeding a cure has been 
effected. If a dark adherent crust forms, repeat as before. 
Healing at last is effected under ten per cent, boric acid in 
vaseline. 

Lactic acid is another powerful caustic, to be applied by 
mixing it with an equal part of finely powdered silica and 
spreading it upon gum-paper. It is kept on for twelve 
hours, and renewed twenty-four hours afterward. Harda- 
way prefers to apply the syrupy acid by means of absorbent 
cotton for ten or fifteen minutes, and then wash off the 
excess of acid with water. This is done daily. Caustic 
potash is recommended by A. R. Robinson for epithelioma 
of the lip. 

The thermo- and galvano-cautery may also be used. 
Resorcin has its advocates, as have chloride of zinc and 
the nitrate of silver. These may be of service where, for 
any reason, a more radical operation is not admissible. 
Fuchsine and methyl-blue, either injected under the skin or 
locally applied, will sometimes seem to stay the progress 
of an epithelioma, but will not cure it. 

There are some cases that are too advanced for any 
active interference, and then palliative remedies only are 
permissible. 

Prognosis. The prognosis of epithelioma as to life is 
fairly good. While, as already said, there are some cases 
that are rapidly fatal, many do not seem to have any effect 
on the patient's health for years. The prognosis as to 
cure is always doubtful. Some cases, whether excised or 
destroyed by other means, will return after a time. If 
they do return, they must be destroyed again. 



242 DISEASES OF THE SKIN. 

Epithelioma Contagiosum. See Molluscurn. 

Epithelioma, Multiple Benign Cystic. Under this title 
Fordyce 1 places those cases formerly described under the 
names of hydradenomes eruptifs, syringo-cystadenome, epi- 
thelioma adenoides cysticum, and others, and reports two 
additional cases. It is characterized by the eruption of 
small, pale-yellow, pearly, pinkish, brownish, or reddish- 
brown tumors from pinhead- to pea-sized, that are located 
on the face, chest, back, and upper extremities. They are 
firm to the touch, and painless. Some of the tumors are 
tense, shiny, freely movable, sometimes with a central 
depression. Some are translucent, like vesicles ; some look 
more like milia. They slowly increase in number, the 
individual tumors enlarging to the size of a pea and then 
remaining stationary. The disease has no effect on the 
general health. In some cases it seems to be hereditary. 
It always begins in early life. 

Microscopic examination shows the tumors to be made 
up of irregular masses and tracts of epithelial cells, and 
"cell-nests." Colloid degeneration of individual cells is 
also seen in the cell-masses. There are also a down growth 
and proliferation of the epidermis and external root-sheath 
of the hair follicle. It is supposed that the growths are 
due to misplaced epithelial cells of indifferent nature. 
(Fordyce.) Their treatment is by curetting. 

Epitheliomatose Pigmentaire. See Atrophoderma pig- 
mentosum. 

Equinia. Synonyms : Glanders ; Farcy ; Malleus ; (Fr.) 
Morve; (Gr.)*R6tz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse, ass, or mule. 

This is a rare disease in the human race, and runs an 
acute, subacute, or chronic course. It is derived by inocu- 
lation with the bacillus mallei, and its symptoms show 
themselves in from three days to six weeks afterward. Its 
constitutional symptoms are fever, prostration, constipation, 
and rheumatic pains, with the subsequent development of 
a typhoid condition in which the patient dies. The objec- 
1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 459. 



ERYSIPELAS. 243 

tive symptoms are a profuse purulent or sanious nasal 
discharge ; chancroidal ulceration at the site of entrance 
of the poison ; phlegmonous inflammation of the affected 
part ; adenitis ; and a cutaneous efflorescence. The latter 
is a disseminated eruption of red macules, which develop 
into yellow papules, upon which variola-like pustules and 
bulla? may form. These may coalesce into superficial 
ulcerations and gangrenous patches. The skin is swollen 
and red, and often crusted with the discharge from the 
pustules. Infiltration of the subcutaneous tissues may 
occur and deep sloughs may form. There may be a gen- 
eral adenitis, and the glands may break down and form 
ulcerating cavities. The whole skin may be involved in 
these destructive processes. It may run an acute or chronic 
course. 

Treatment is usually unavailing, and is on general prin- 
ciples. The prognosis is bad. The more acute the symp- 
toms the worse the outlook. 

Erbgrind. See Favus. 

Erysipelas. Synonyms : (Fr.) La rose, Feu sacre ; 
(Ger.) Rothlauf, Rose, Hautrose, Wundrose; (It.) Risi- 
pola ; St. Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin or the adjacent 
mucous membranes, attended always with redness and 
swelling, and often with vesicles, bulla?, pustules, diffuse 
suppuration, and gangrene ; and characterized by a ten- 
dency to spread at the periphery and by fever. (Foster.) 

Symptoms. Though the most modern pathology 
teaches that erysipelas always originates in or about a 
lesion of the skin or mucous membrane, and is therefore 
allied to if not identical with the same disease as met with 
in surgical and lying-in wards, so-called surgical erysipelas 
will not be considered here. The outbreak of the disease, 
as met with apart from the surgical form, is usually pre- 
ceded for a day or so with malaise, and the attack is often 
ushered in with a chill, pyrexia, and vomiting. The fever 
is present throughout the whole course of the disease, ex- 
cepting in the most mild type, when it may soon subside. 
The thermometric range is from 101° to 105.5° F. There 



244 DISEASES OF THE SKIN. 

will be other signs of constitutional disturbance, such as a 
coated tongue, a quickened pulse, either full, soft, and 
compressible, or, in bad cases, small and weak ; headache, 
drowsiness, or, in bad cases, delirium • and sometimes 
albumin is found in the urine. 

The most frequent location of the disease, so far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, 
sharply defined, irregularly shaped, hot to the touch, and, 
at first, with a smooth glazed surface. The redness may be 
pressed out with the finger, leaving a yellow stain, but 
pr< >mptly returns when the pressure is removed. The patch 
enlarges, creeping with more or less rapidity over the sur- 
face, always preserving its sharp, ofttimes indented border 
that is raised toward the sound skin ; it becomes of a 
darker hue, sometimes livid ; and very commonly, though 
not uniformly, vesicles or even blebs form on it. These 
latter may become purulent, and breaking, discharge their 
contents upon the surface, which dry into crusts. As the 
process extends the central portion becomes flattened and 
less red. Sometimes new patches may appear, and coalesce 
with the original patch. Sometimes, while spreading pe- 
ripherally, there may be a recrudescence in the older parts. 
The area of the disease may be limited or may include the 
whole body. Very often it seems to be checked by the 
line of the hair, whether of the beard or scalp. Not un- 
commonly it invades the hairy parts, involving one-half 
or the whole of the scalp and extending down upon the 
neck. Then the patient's appearance is indeed deplorable. 
His lips are swollen and livid, his eyelids are swollen so 
that the eyes cannot be opened, and his head seems enor- 
mously enlarged. At times there may be a lighting up of 
the disease on a distant part of the body, as on the arm 
with erysipelas of the face. The lymphatics and the lym- 
phatic glands are involved. The former often show them- 
selves as red streaks. The glands may suppurate, and 
gangrene of the skin may declare itself. All grades of 
inflammation may be reached. Sometimes the disease is 
but slight, sometimes very severe, the constitutional symp- 



ERYSIPELAS. 245 

toms keeping pace with the severity of the local symptoms. 
The duration of the disease may be six or seven days, or 
two or three weeks. The patient is always more or less 
prostrated by it, though many of the cases we see are 
ambulant cases. 

• The subjective symptoms are burning, tingling, itch- 
ing, and tension. The parts are often tender, and may be 
spontaneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy-red, raised 
line. Sometimes recurrent attacks occur at short inter- 
vals; generally the disease does not recur. When the 
scalp is invaded the hair commonly falls during conva- 
lescence. Sometimes some lesion of the skin may be found 
as the starting-point of the inflammation, or perhaps some 
lesion of the mucous membrane of the nose, mouth, or 
ear. In the recurrent attacks the nose is quite commonly 
the peccant member. But in a very large proportion of 
cases no lesion at all will be discoverable. When the dis- 
ease subsides the skin desquamates, and returns at last 
to the normal condition. 

Erysipelas occurring upon the trunk or extremities pre- 
sents pretty much the same symptoms as when occurring 
upon the face. 

Etiology. It is now generally accepted that the dis- 
ease is infectious, and caused by a specific micro-organism 
that was described by Fehleisen. 1 This gains access to 
the body through some lesion of continuity of the skin or 
mucous membrane, however minute that may be. It 
therefore sometimes follows boils, tubercular ulcers, ec- 
zema, and other skin diseases. As in many of the bacterial 
diseases, so in this one, it is probable that the patient must 
be in the proper condition of health, or rather ill-health, 
for the lodgement of cocci. One attack predisposes to 
another attack. It is more frequent in women than in 
men ; and in winter than in summer. Intemperance, 
Bright's disease, parturition, and a lowered state of nutri- 
tion predispose to it. While the contagiousness of sur- 
1 Deutsche Zeitschrift f. Chirurgie, 1882, xvi., 391. 



246 DISEASES OF THE SKIN. 

gical erysipelas is well known, and commonly observed, 
it is rare to meet a case of facial erysipelas traceable 
directly to contagion. The possibility of the occurrence 
of the disease without infection by the micro-organism is 
still entertained. It has been thought to arise from taking 
cold or to begin in some circumscribed purulent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch ad- 
vancing with more or less steadiness over the surface, the 
process being preceded by a chill and accompanied by 
marked constitutional disturbance, there is little danger of 
mistaking it. It may, however, be mistaken for an acute 
erythematous eczema, an erythema, or so-called giant urti- 
caria. In eczema the parts are not so swollen ; the margin 
of the patch fades into the surrounding skin ; the color is 
not so brilliant ; the surface is rougher and more scaly ; 
there is decided itching and a lack of constitutional dis- 
turbance of any magnitude. Erythema lacks the consti- 
tutional symptoms of erysipelas ; the redness fades com- 
pletely away under pressure, without leaving a yellowish 
stain, and springs back promptly when the pressure is re- 
moved ; it does not creep over the skin ; and it is of short 
duration. In urticaria there will usually be well-marked 
wheals or a history of them; great itching; no tenderness; 
a short course ; a history or evidence of digestive disorders, 
and an absence of marked constitutional disturbance. 

Treatment. The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the fact 
that most cases recover of themselves. There are not a few 
competent observers who are skeptical of the real efficacy 
of any local treatment. As the disease tends to lower 
the vitality of the patient, we should strive to support his 
strength by a most nutritious diet, and by alcoholic stimu- 
lants in adynamic cases. The internal medication will 
be symptomatic to a large extent, by means of aconite, 
quinine, antipyrine, phenacetine, and the like. The tinct- 
ure of the chloride of iron, in twenty- to sixty-minim 
doses every two or three hours, is regarded by many as a 



ERYSIPELAS. 247 

specific, and should be given in all but the slightest cases. 
Jaborandi by the mouth, or pilocarpine, one-sixth to one- 
quarter of a grain hypodermically, have their advocates, 
but must not be thought of in debilitated subjects. 

The local treatment is very important. If there is a 
wound present, it should, of course, be thoroughly disin- 
fected on surgical principles. The lead-and-opium wash 
is an old remedy, and has proved useful in very many 
cases. It is composed of 



R Liq. plumbi subacetat. dil., 3J-iij ; 4-12 

Tinct. opii, 31J— iv ; 8-16 

A quae, ad Oj ; ad 500 



M. 



It may be used hot or cold, whichever is most agreeable 
to the patient. Dry heat will also relieve the discomfort 
of the patient. Resorcin in watery solution of two or 
three per cent, strength seems at times to cut short the 
disease. Duckworth 1 commends chalk ointment, made of 
equal parts of melted lard and chalk, with or without a 
half-drachm of pure carbolic acid to the ounce. This is 
to be smeared on thickly and covered with plain or boric 
lint. "White-lead paint has done well in some hands. 
White 2 expects to cure his cases of ordinary facial ery- 
sipelas by keeping the part constantly covered with cloths 
saturated with the following: 



R Ac. carbolici, 3J > 4 

Alcohol.,! ^ a&250 

Aquae, J ' 



M. 



It may be used every alternate hour. Carbolic acid may 
also be used in oil, ten per cent, strength, and rubbed in 
every hour. Piffard recommends the external use of: 

R Tinct. belladonna, 1 part. 

Glycerini, 1 " 

Aquae, 8 parts. M. 

Shoemaker is fond of the ointment of the oleate of bis- 

1 Practitioner, January, 1887. 

2 Trans. Araer. Dermat. Assoc, 1890, p. 42. 



248 DISEASES OF THE SKIN. 

muth. Ichthyol, in twenty-five to fifty per cent, aqueous 
solution, is one of the best applications, the only objections 
to it being its disagreeable odor and dark-brown color. 
The parts should be constantly covered with it. 

The treatment by scarifications about the patch, the in- 
cisions being made diagonally, partly in the sound and 
partly in the diseased skin, and then covered with gauze 
wet with a solution of bichloride of mercury, 1 : 1000, 
is known as the Kraske-Riedel method, and should be 
always thought of in grave cases. Woelfler 1 recommends 
compression of the border-line by adhesive-plaster strips, 
the disease seldom spreading beyond the constricting band. 
This is specially applicable to erysipelas of the limbs. 
Painting with nitrate of silver all around the patch has 
also been done, with the idea of checking its spread. 

Pkogxosls. Many cases of erysipelas recover of them- 
selves in a few days, while others may run a course of 
weeks. The prognosis may be said to be good in most 
cases ; but even in those that begin as mild ones we should 
be on the watch for grave symptoms. When the scalp is 
affected the prognosis is more grave than when the face 
alone is the seat of the disease. When the patient is the 
subject of chronic alcoholism, or Bright's disease, or is in 
the puerperal state, the prognosis is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelas-like eruption unattended by constitu- 
tional symptoms. It is also called chronic erysipelas and 
erythema migrans. It originates in a wound, is due to 
infection from some dead, putrefying animal substance, 
and chiefly affects cooks, butchers, fishmongers, and the 
like. It occurs mostly on the fingers, and spreads from 
the point of inoculation as a dark-red, often livid swelling 
with a sharp border. As it travels over the surface the 
central portion undergoes involution, and thus circles or 
scalloped patches may be formed. It stops spontaneously 
after from one to six weeks' duration. There is marked 
itching or burning during the whole course of the disease. 
It is distinguished from true erysipelas by the mildness of 

1 Wien. klin. Wochcnschr., 1889, Nos. 23 and 25. 



ERYTHEMA. 249 

its symptoms. A salicylic acid or other antiseptic oint- 
ment may be used in treatment. 

Erythema. Synonyms : Dermatitis erythematosa, Ery- 
sipelas suffusum • (Fr.) Erythenie, Dartre erythemoide ; 
(Ger.) Erythem, Hautrothe ; Rose rash. 

Erythema may be passive or active. The former is 
familiar as lividity of the skin, and the latter as blushing. 

There are many forms of erythema as a disease, but 
they may all be classed under one of two main varieties, 
namely, Erythema hypersemicum and Erythema exuda- 
tivum. I shall follow Crocker's classification, as it is a 
practical one. It is a question whether erythema should 
be regarded as a disease or a symptom. 

IE. simplex. 
E. pernio. 
E. intertrigo. 
E. Iseve. 
_....._ E. paratrimma. 

IE. fugax. 
E. urticans. 
E. roseola. 
E. scarlatiniforme. 
E. multiforme. 

lnodoS eSiriS - 
E. gangrenosum. 

Eeythema Hypersemicum. 

This form of erythema is characterized by simple red- 
ness without swelling, and usually is not followed by des- 
quamation. This shows that it is due simply to a local- 
ized hyperemia without inflammation. It is always of 
short duration. The redness disappears under pressure, 
but springs back again as soon as the pressure is removed. 
It occurs either in circumscribed patches of large or small 
size, or diffused over large areas. Subjective symptoms 
are often hardly noticeable. There may be some burning 
and tenderness, but there is never decided itching. The 
patient may rub his skin gently, but never scratches 
violently. In cases due to internal causes there may be 
slight constitutional symptoms with fever of mild grade, 
or some digestive disturbance ; but these are not properly 
symptoms of the erythema, but rather of the underlying 



250 DISEASES OF THE SKIN. 

disease of which the eruption is but an accidental expres- 
sion. For instance, two people may eat the same thing. 
In both there may be digestive disturbances. But one 
will have an erythema and the other will escape. 

This form of erythema may arise from either external 
or internal causes. Cases arising from external causes 
are localized, while those due to internal causes are 
general. Both are angio-neuroses, and predisposed to 
by an inborn susceptibility — that is, idiosyncrasy of the 
patient. 

In the first group we have Erythema simplex, under 
which are included E. traumaticum and E. caloricum, due 
to the rubbing of the clothing, the effect of heat or 
cold, as of the sun or wind, and of various vegetable or 
chemical irritants. Many of these simple erythemas I 
have already described under the caption of Dermatitis, 
which see. They are the simplest reaction of the skin to 
an irritant. If the irritant is great enough or lasts long 
enough, a dermatitis is set up. They are usually localized, 
and for treatment require only the removal of the irritat- 
ing cause, and the application of a simple dusting powder 
or ointment. The exciting cause continuing, we have 
inflammation added and a dermatitis produced. 

Erythema Pernio has been described under Dermatitis 
congelatio, which see. 

Erythema Intertrigo, or simply Intertrigo, is an ery- 
thema occurring between two folds of skin. It is most 
commonly seen in fat infants in the folds of the skin of 
the neck and joints. It is also encountered in adults who 
are corpulent, and is often a very annoying trouble in 
women, in whom it frequently occurs underneath the 
hanging breasts. It also occurs between the scrotum and 
inside of the thighs, under the prepuce, in the furrows 
alongside of the vulva, in the joints, and in all other skin- 
creases. It is then caused by the friction in walking and 
favored by heat and moisture. It is therefore more 
common in warm weather. If not at once and properly 
attended to, the decomposition of the sweat and sebaceous 
matters will aggravate it; and the irritation being con- 
tinued, an eczema will develop. It is, in infants, very 



ERYTHEMA. 251 

common about the inside of the thighs, where the wet 
napkins cause and aggravate it. It is very often accom- 
panied by a disagreeable, cheesy odor, and, contrary to 
what obtains in other erythemas, there is moisture upon 
the skin in some cases. 

Diagnosis. The diagnosis from eczema is very often 
difficult. Indeed, eczema and erythema run into each other 
so imperceptibly at times that it is difficult to tell where the 
one leaves off and the other begins. But eczema itches 
more than erythema, it tends to spread further beyond the 
affected part, and its exudation is not only sticky, but also 
stains and stiffens linen. The location in the skin-folds 
should suggest an intertrigo. Happily, the differentiation 
is a matter of no great importance, as the same treatment 
is applicable to both. 

In infantile syphilis we frequently have an eruption 
upon the buttocks and inside of the thighs that bears a 
decided resemblance to intertrigo. Here a correct diag- 
nosis is of great importance. In syphilis the redness com- 
monly extends down the whole inside of the legs to the 
feet and soles, it is of a darker color, and there will be 
other symptoms of the disease, such as snuffles, large or 
small papules to the outside of the red patch, mucous 
patches, and the like. In infant asylums, where a great 
number of debilitated as well as syphilitic children are 
received, opportunities for the differentiation between 
syphilis and intertrigo frequently occur. 

Treatment. The treatment of intertrigo is simple. 
The apposing surfaces of skin must be separated by pieces 
of gauze or muslin, the furrows must be kept perfectly 
clean, and dusting powders of starch, talc, lycopodium, 
and the like, must be freely used. To these powders oxide 
of zinc, boric acid, or other astringents may be added, the 
compound stearate of zinc being one of the best applica- 
tions. Hardaway recommends : 

R Thymol., gr. j ; 1O6 

Pulv. zinci oleat., gj ; 32) M. 

As a rule, powders answer better than ointments, though 
Lassar's paste, as given under Eczema, may be used. 



252 DISEASES OF THE SKIN. 

Lotions, such as calamine lotion, and a saturated solution 
of boric acid, are preferable to ointments. The treatment 
of intertrigo in infants is to be managed in the same way 
as eczema. (See under Eczema infantile.) 

Erythema Lceve is an obsolete term, which was employed 
to indicate the redness seen on cedematous limbs. 

Erythema Paratrimma belongs to the same category, 
only here it is the redness over bony prominences, as that 
preceding a bedsore. 

We have now to consider the second group of erythema 
hyperaemicum, those erythemas which are due to internal 
causes. Here might be placed all the exanthematous 
fevers, as well as the drug-eruptions. But the first of 
these belongs to the domain of general medicine, and the 
last will be found under Dermatitis medicamentosa. 

Erythema Fugax is, as its name indicates, a fugitive 
erythema — as it were, a prolonged blush. It is seen most 
often in children with some digestive disturbance, and its 
chosen location is the face. It lasts for a few moments or 
hours, and is seldom seen by the physician, although he 
will be told, not infrequently, by patients that they are 
annoyed by a flushing of the face after eating, exposure 
to cold, or mental emotion. It is to be managed like 
Urticaria, which see. 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Roseola, or simply roseola. While children 
are more subject to this form of erythema than adults, 
it may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in most, 
if not all, cases to digestive disorders or other constitu- 
tional disturbance, it is usually ushered in with a rise of 
temperature, which may be pretty sharp, 103° or 104° F., 
furred tongue, restlessness, and the like. Soon the erup- 
tion appears, which may be a blotchy redness, or in faintly 
marked papules, or in rings or gyrate figures. The erup- 
tion lasts a few hours only, or, coming and going in differ- 



ERYTHEMA. 253 

ent places, it may be prolonged for a few days. Besides 
digestive disorders, gout, changes of temperature, and the 
seasons of spring and autumn have been assigned as causes. 

Diagnosis. In itself it is a matter of little moment, 
but as it resembles scarlet fever, rotheln, and measles, its 
diagnosis is important. It differs from scarlatina in not 
having such severe constitutional symptoms ; in an absence 
of the strawberry tongue, swollen, reddened fauces, and 
enlarged glands ; in the rash coming out all over the body 
without following any regular course of development from 
the neck downward ; in the eruption being blotchy or 
papular, and not a diffused redness. After watching the 
Case for a day the diagnosis will be evident by the clear- 
ing away of the disease wholly or partially. It differs 
from measles in an entire absence of catarrhal symptoms, 
and in its eruption not being crescentic, as well as in the 
irregularity of its course, the mildness of its symptoms, 
and the brightness of its color. It bears most resemblance 
to rotheln, and probably the two are often confounded. If 
there is a clear history of contagion, or more than one 
member of the family affected at the same time, the diag- 
nosis of rotheln is at once established. Rotheln is more 
pronounced on the extremities, and the lesions are of a 
more stable character. In case of doubt as to diagnosis 
of roseola the patient should be regarded as having a con- 
tagious disease, isolated, and carefully watched. 

Treatment. Little need be done for the patient but 
to give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the first 
few days of life, and is thought to be due to the influence 
of external and unusual irritants acting upon the tender 
skin of a newborn child. " The eruption consists of very 
minute red papules, seated upon a hypersemic base, which 
can be made to lose their color upon pressure. The lesions 
are most pronounced upon the back and breast, and fade 
away in a few days with slight desquamation of the most 
congested spots. The mucous membranes are unaffected, 
and there is no evidence of systemic reaction." (Hard- 
away.) 



254 DISEASES OF THE SKIN. 

Erythema Scarlatiniforme. A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 
frequently mentioned in the section on Dermatitis medica- 
mentosa. The French authors describe a scarlatiniform 
erythema under the name of erythemes scarlatiniformes 
reeidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first described 
by Fereol in 1876, at the Societe medicale des Hopitaux 
de Paris. The disease is marked by redness, desquama- 
tion, and relapses. Its outbreak may or may not be pre- 
ceded for one or two days by malaise and slight febrile 
movement. It begins on the trunk and invades the whole 
surface in a few hours or in two days. It is a diffused, 
uniform, intense, scarlatinal or somber-red eruption. 
There may be slight differences in the shade of color, or 
the redness may be punctate, or some pinhead-sized vesicles 
may develop upon it. Sometimes the eruption is limited 
to a certain portion of the body ; sometimes the eruption 
is general, but not universal, normal islands of skin being 
found in the general redness. It comes out in patches 
that run together. There is generally redness of the 
mucous membrane of the mouth and fauces. There is no 
thickening of the skin nor infiltration of mucous mem- 
branes. The skin burns, and there may be itching. Ex- 
foliation of the skin begins almost as soon as the eruption 
is out, commencing at the point of invasion. The des- 
quamation is general, and may be furfuraceous, or abundant 
and in large plaques. Upon the scalp it is furfuraceous. 
The whole process may take but one or two days, or it 
may be prolonged for a month or six weeks. The hair 
and nails may be shed. The tongue is furred, and may 
desquamate, but never presents the papilla? of scarlatina. 
After the beginning of the attack there is usually no fever, 
and the appetite is preserved. There may be albumi- 
nuria during the attack. The relapses, which are apt 
to occur after intervals of days, months, or years, are 
less pronounced and the patient's health is good in the 
interim. 

Etiology. The cause of the disease is very often 

1 Ann. de derm, et de syph., 1890, i., 1. 



ERYTHEMA. 255 

obscure. The first attack has been observed to follow 
exposure to cold, the application of mercurial ointment, 
or the action of some other irritant. But it is difficult to 
explain why from such causes relapses should occur. 
Besnier thinks that in some cases the cause is a poison 
developed within the individual. In this way he would 
explain some of the erythemas developing during an acute 
urethritis, which some observers claim may arise indepen- 
dently of the taking of copaiba. Scarlatiniform erythemas 
occur occasionally in septicemic conditions, in typhus fever, 
in malaria of children, in sewer-gas poisoning, and in 
various other conditions. 

Diagnosis. Brocq considers scarlatiniform erythema 
as one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
having no permanent effect upon the health, by running a 
shorter course, and by the skin not being dry, contracted, 
and shrivelled. It differs from scarlatina in the mildness 
of its constitutional symptoms; by the course of the erup- 
tion ; by the absence of tumefaction of the fauces and the 
strawberry tongue ; by the early desquamation ; by not 
being contagious ; and by its tendency to relapse. If there 
is any doubt as to the diagnosis, the patient should be 
isolated. It differs from erythematous eczema in an entire 
absence both of thickening and moisture ; in being less 
itchy ; and in its rapid course. 

Teeatment. The treatment is purely symptomatic. 

EEYTHEMA ExiTDATrVTTM. 

The second variety of erythema differs from erythema 
hypersemicum in the presence of an exudation into, not 
on, the skin, so that the patches are raised above the level 
of the skin, and in never involving the whole surface, but 
always occurring in circumscribed patches. It is an in- 
flammatory disease. Its several varieties are alike in that 
the redness disappears under pressure, to return at once 
when the pressure is removed. It is probable that ery- 
thema nodosum is really but a part of erythema multiforme, 
as the two forms may be present at one time. But it is 



256 DISEASES OF THE SKIN. 

usually described apart, and although this may not be 
strictly accurate, it is convenient. 

Erythema (Exudativum) Multiforme, as its name indicates, 
is very multiform in its efflorescences. For a day or a few 
days before they appear there is some constitutional dis- 
turbance. This may be nothing more than slight malaise, 
the patient not feeling as well as usual. From these 
indefinite symptoms there are all grades up to fever of 
104° F., headache, gastric disturbances, and severe muscu- 
lar and articular pains, like rheumatism. According to 
Besnier and Doyon, an erythema of the pharynx, or a 
pharyngitis, laryngitis, or bronchitis, often precedes or 
accompanies the outbreak of the eruption upon the skin. 
The eruption is most constantly seen upon the backs of 
the hands and feet, and here it commonly begins, though 
this is denied by Polotebnoff, to whom we are indebted for 
a most exhaustive and able study of erythema.' 1 It also 
appears on the trunk and extremities more or less gener- 
ally, coming out in crops, and preserving a rough sym- 
metry. Sometimes it may remain confined to a single 
region, as the backs of the hands. Sometimes it occurs on 
the mucous membranes, as of the mouth and eyes. It is 
usually most marked and abundant about the joints should 
they have exhibited rheumatic pains. It is rare not to 
find lesions upon the backs of the hands. With the ap- 
pearance of the eruption there is a subsidence of the con- 
stitutional symptoms, though in many cases the patients are 
more or less definitely ill during the whole course of the 



The eruption commences as a group of deep-red papules 
from pinhead- to pea-size, conical or rounded, and this is 
called erythema papulatum. The eruption may continue 
as such ; or the papules may coalesce and form elevated 
patches, sharply marked against the sound skin ; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the center and ring-shaped, the periphery 
being deep red while the center is purplish. This is called 
erythema circinatum or annulare. Sometimes it happens 
1 Zur Lehre von den Ervthemen. Hamburg, 1887. 



ERYTHEMA. 257 

that the ring still enlarges by successive exudations, and 
then there will be ring within ring, the outer one pink, the 
next red, the next purplish, thus forming an iris-like play 
of colors that has been termed erythema iris. Two rings 
near each other and enlarging will after a time meet at 
their peripheries, the points of contact will melt into each 
other and disappear, and there will form a large patch with 
a figure-of-eight or scalloped, raised border, and a flattened 
center. This is called erythema marginatum. It may 
travel over a large part of the trunk or the circumference 
of a limb, leaving a fawn-colored pigmentation, which soon 
fades. Or two rings meet, and each breaks, and only a 
gyrate line is formed, to which the name of erythema 
gyratum is applied. Sometimes, though rarely, the exuda- 
tion is so abundant that the epidermis is raised in the form 
of vesicles or bulla?. This is erythema vesiculosum seu 
bullosum. Hemorrhage may take place into the bullae. 

It is uncommon to find all these forms present at the 
same time, nor must it be understood that one form neces- 
sarily evolves into the other. The evolution may stop at 
any stage ; most often at the papular stage. Neverthe- 
less, more than one form is usually to be seen, so that the 
term multiform is merited. Crocker says that in children 
multiformity is less the rule, the constitutional symptoms 
are more pronounced, and if vesiculation occur the vesi- 
cles are more prone to become purulent and leave scars. 

The duration of the disease is from two to four weeks, 
but it may be extended by a succession of outbreaks for 
months or years. The eruption is attended by burning 
rather than itching, and sometimes by a feeling of tension. 
Slight pigmentation may be left, but it is transitory. 
Desquamation may follow the eruption, but it is not com- 
mon. In some patients there is a decided tendency to 
relapse at irregular intervals for years. In Prof. George 
Henry Fox's service at the Vanderbilt Clinic I have seen 
a boy with a relapsing bullous erythema of the face and 
ears that had appeared at intervals during ten years. The 
bulla? were of large size, fully distended, and of irregular 
shape. They left depressed, pigmented cicatrices in some 
places. Similar cases have been reported by others, as, 

17 



258 DISEASES OF THE SKIN. 

for instance, by Hardaway, who saw one case with re- 
lapses for four years ; and T. C. Fox, who saw two cases 
with a duration of sixteen years in each case. 

As complications of erythema multiforme, and espe- 
cially of erythema nodosum, have been reported endo- 
and peri-carditis, meningitis, pleurisy, pneumonia, and the 
like; but it is better to regard these diseases not as com- 
plicating the erythema, but as the primary diseases of 
which the erythema is a phenomenon. 

Erythema Iris. This very rare disease was formerly re- 
garded as a herpes, and is described in many text-books as 
herpes iris. Its other synonyms are hydroa, herpes circi- 
natus, and hydroa vesiculeux. It is only a form of ery- 
thema multiforme. It is seen sometimes along with other 
manifestations of erythema multiforme, or with herpes, 
though it usually occurs alone. It is located most often 
upon the backs of the hands and feet, and upon the arms 
and legs, but it may occur anywhere upon the skin as well 
as the mucous membranes. I have seen one ease upon 
the buttocks as well as upon the elbows. According to 
Crocker, there are two varieties of the disease, one with a 
central vesicle or a purplish depression surrounded by one 
or more whitish rings slightly raised up by effused fluid ; 
the other with a central bulla with one or more rings of 
more or less discrete vesicles round it. Of these two, the 
first is the more frequent. 

The first variety begins as a small erythematous papule 
upon which a pinhead-sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 
preserves a red areola. When about a quarter of an inch 
in diameter the fluid is absorbed in the center, leaving a 
purplish depression ; or only a ring of absorption occurs, 
so that there will remain a vesicle in the center with a 
purplish zone about it, then a raised white ring, and 
around all a narrow pink areola. This play of colors 
gives the name of iris. The patch may reach the diameter 
of half an inch, and then undergo involution ; or several 
patches may unite and form patches of one inch or more 
in diameter, and hemorrhage may take placa into the 
bullae that may form. 



ERYTHEMA. 259 

In the second variety, which is the hydroa vesieuleux 
of Bazin, round a central bulla a ring of split-pea-sized 
vesicles forms, the vesicles being either discrete or touch- 
ing. A second or a third ring of vesicles may form out- 
side of these, the skin between them being of a purplish 
tint. The bulla? and vesicles may leave scars. Crusting 
also takes place from the breaking or drying of the vesi- 
cles. 

The lesions of both varieties are more or less symmet- 
rical, though a patch may develop on one side several 
days before the other. The duration is from three to four 
weeks or longer. Relapses are common. Burning is 
usually pronounced, and there may be some itching. 
From this description it will be seen that the so-called 
herpes iris is really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and erytheme noueux (Fr.), is more common than ery- 
thema iris, but not nearly so common as erythema multi- 
forme. It is only a variety of erythema multiforme, as it 
may occur as a part of that disorder. In the vast majority 
of cases it occurs alone. Its prodromal symptoms are 
substantially the same as those of erythema multiforme, 
but its rheumatic pains are more pronounced and nearly 
always present. There are also tenderness and pain over 
the tibia?. After a few days of prodromata, round or, 
more often, oval, bright or rosy-red swellings appear over 
the tibise, with their long axis vertical. These are from 
nut- to egg-size; raised; their borders merge gradually into 
the surrounding skin • they are painful and often exqui- 
sitely tender; firm at first, but may be semi-fluctuating 
afterward ; and their color darkens to a dark red, then 
purple, and in undergoing absorption they present the 
appearance of a black-and-blue spot from a bruise. The 
color at first disappears under pressure, to spring back 
when the pressure is removed. The changes of color 
subsequently seen are due to the gradual absorption of 
the coloring-matters of the blood deposited in the tissues. 
There are usually not more than a dozen lesions, gener- 
ally less. They are most frequently located over the 
tibise, but may occur as well upon the arms, scapulae, 



260 DISEASES OF THE SKIN. 

thighs, and raucous membranes. They are roughly sym- 
metrical. The duration of the disease is, like that of 
other erythemas, two to four weeks. 

Etiology. The causes of erythema exudativum are 
not fully determined. It is probably due to some toxic 
condition of the blood, which may develop in the indi- 
vidual or be derived from without. It occurs more com- 
monly in women than in men, and in young adults rather 
than in old people, while erythema nodosum is said to be 
most frequent in children. It is most frequent in the 
spring and autumn seasons, in which dampness and cold 
winds prevail, and sudden changes of temperature are com- 
mon. The papular erythema is very often seen in recently 
arrived immigrants. Rheumatism has a well-marked 
causal relation to erythema nodosum, and, it may be, to 
the other forms. Syphilis seems to be an etiological factor 
of some weight in the production of erythema nodosum. 
Some years ago I saw in the service of Prof. E. B. Bran- 
son, in the New York Polyclinic, a well-marked instance 
of this in the course of recent syphilis in a woman. Many 
cases seem to be due to systemic poisoning either by some 
infectious disease or by auto-infection. Some authorities 
are of the opinion that such cases should be separated 
from erythema exudativum, and propose the name of 
polymorphous erythema. It is seen with cholera, influenza, 
and the exanthemata ; with indigestion, pregnancy, par- 
turition, menstrual disturbances, kidney diseases, and 
various other internal or systemic disorders. Sometimes 
the disease seems to be a pure angio-neurosis. Cases of 
erythema multiforme recurring with recurring attacks of 
gonorrhoea have been reported. These appear as reflex 
angio-neuroses without the ingestion of balsamics in the 
treatment of the urethritis. Cases of erythema multiforme 
not infrequently follow the ingestion of drugs; at least 
they are almost identical with it in appearance. Sometimes, 
according to Polotebnoff, it seems to be an abortive form 
of prevailing epidemics. Cases certainly should be watched 
carefully in connection with other symptoms, as they may 
be but part of the prodromata of sonic grave disorder. 
I have seen two cases in which a well-marked erythema 



ERYTHEMA. 261 

multiforme preceded for about ten days the outbreak of 
typhoid fever; the erythema then disappearing and the 
characteristic typhoid eruption coming in due course. 
Many of the subjects of erythema are debilitated. Indi- 
vidual predisposition probably plays an important role in 
the etiology of some cases, especially in the relapsing 
ones. 

Pathology. All forms of the disease show not only 
hyperemia, but also inflammatory effusion both of fluid 
and leucocytes. Upon the amount of this fluid depends 
the character of the lesion. If small in amount, it will 
simply push up the epidermis into a papule or tubercle ; 
if of larger amount, we shall have vesicles and bullae. 
There is also an escape of the coloring-matter of the blood 
into the tissues. (Crocker.) 

Diagnosis. If the characteristics of erythema multi- 
forme are borne in mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright 
or rosy-red lesions, located by preference upon the back of 
the hands and feet ; and the color that fades away entirely 
under pressure, to return again when pressure is removed, 
and in disappearing leaves stains. It most resembles 
urticaria, but differs from it in having more stable lesions 
of more varied shape ; in absence of wheals ; in occurring 
particularly on the back of the hands and feet ; and in 
burning rather than itching. The papular form differs 
from papular eczema, in its chosen locations ; in its burn- 
ing rather than itching ; in its papules being larger and 
never developing vesicles nor forming patches; in an 
absence of thickening of the skin ; in disappearing com- 
pletely under pressure ; in tending to get well without 
treatment ; and in leaving stains. The nodes of erythema 
nodosum differ from syphilitic gummata in occurring sud- 
denly and not gradually. In syphilis the redness does not 
occur until after the node has existed for some time, and 
the nodes are not tender nor developed symmetrically. 
Moreover, there would be other evidences of syphilis. 

Treatment. Villemin * maintains that iodide of po- 
tassium, in doses of at least thirty grains a day, is almost a 
x Gaz. hebdom., May 24, 1886. 



262 DISEASES OF THE SKIN. 

specific, and will abort relapses. The experience of Besnier 
and others has not been in accord with that of Villemin. 
Quinine, twenty to thirty grains a day, and salicylate of 
soda in fifteen-grain doses three or four times a day some- 
times abort or check the disease. Arsenic may be tried in 
chronic cases. The treatment is mainly symptomatic, and 
directed to relieving the constipation, regulating the diet, 
aiding digestion, ameliorating rheumatism, or toning up 
the system. In obstinate cases the patient had best be 
kept in bed. Locally any alkaline lotion will afford relief, 
such as 



Or, 



R Pul. calamin. pnep., ^ij ; 4! 

Zinci oxid., £ss ; 3 

Liq. calcis, ad ^ij ; ad lOOJ M. 

R Liquor plumbi subacetatis, tt\,xv ; 31 

Aqua, gj; 100| M. 



Or, lead-and-opium wash, hamamelis, or other evaporat- 
ing solutions. Ointments should be avoided, as they do 
no better than lotions and are disagreeable to use. 

Sometimes a simple dusting powder will do as well. In 
erythema nodosum the patient should be kept in bed, and 
the lotion is often more agreeable to the patient when used 
warm. Salicylic acid or salicylate of soda internally may 
afford relief to the sometimes intense pains. Regulation 
and simplification of the diet, and the administration of 
diuretics or tonics, according to the nature of the case, 
will do good in the disease as seen in immigrants. 

Prognosis. The disease tends to spontaneous cure. 
Relapses may occur, though they are by no means the 
rule. Exceptionally the disease may run a protracted 
course, but recovery may be expected. 

Erythema Centrifuge. See Lupus erythematosus. 

Erythema Elevatum Diutinum. Under this caption 
Crocker 1 and others describe a form of erythema that is 
said to occur in girls with a rheumatic history. It de- 
velops over the articular prominences of the fingers, elbows, 
1 Brit. Journ. Dermat., 1894, vi., 1. 



ERYTHEMA. 263 

and knees, and also on the palms, toes, and buttocks. Its 
lesions are nodular, with a tendency to coalesce into ele- 
vated infiltrations that are most marked on the palms. 
They tend to persist, but may undergo involution. Their 
color is at first pink, but soon becomes purple. The older 
lesions become firm and almost cartilaginous, and are 
always incompressible. The lesions are always sharply 
defined against the skin. Histologically the disease is an 
inflammatory process accompanied by the production of 
fibrous tissue. 

Erythema Gangrenosum, though described as a disease, 
is probably, in most instances, a feigned eruption. In it 
rosy, irregular patches appear on different parts of the 
trunk and extremities, which, at first smooth, after a 
few days become dry and harsh and covered with a thin 
scale. 

Erythema Induratum Scrofulosorum is a disease first 
described by Bazin as erytheme indure des scrofuleux. 
It consists in an eruption of nodular lesions that may 
remain deep-seated for a considerable time, so that they 
can be made out only by palpation. After a while the 
overlying skin becomes red, and later violaceous, and the 
lesions resemble those of erythema nodosum. In size they 
vary from that of a hazelnut or larger on the legs, to smaller 
on the fingers. They are round or ovoid in shape. They 
are usually few in number and discrete, but may be numer- 
ous and confluent. They are indolent in their course, and 
may undergo involution, or suppurate or necrose en masse. 
Poly cyclic ulcers may form. There may or may not be 
pain or tenderness. They are located most often on the 
legs in young people, especially in girls of poor general 
health and circulation, who stand a great deal and who 
suffer from chilblains in winter, but may occur in others 
who present none of these peculiarities. 

They differ from erythema nodosum in their more cir- 
cumscribed form, firmer consistence, darker color, deeper 
seat, absence of tenderness, tendency to ulcerate, and more 
protracted course. Syphilitic gummata are not bilateral, 
and usually other symptoms of syphilis can be found. 



264 DISEASES OF THE SKIN. 

The treatment consists in rest in bed, elevation and 
compression of the legs, and general tonics. 

Erythema Mamelonne\ See Erythema roseola. 

Erythema Migrans. See Erysipeloid. 

Erytheme Noueux. See Erythema nodosum. 

Erytheme Papuleux Desquamatif (Tidal). See Pityri- 
asis maculata et circinata. 

Erythrasma. A contagious parasitic disease of the skin, 
occurring especially in the groins and axillae in the form 
of sharply defined, brownish-red, desquamating patches, 
bordered by a fringe of broken and partly detached epi- 
dermis. (Foster.) 

The disease begins as a little yellowish point that soon 
becomes a lentil-sized macule, and grows into a patch the 
size of a silver dollar or the hand. Several patches join 
together, so that large surfaces may be involved. The 
] latches are oval or disk-shaped, or irregular in outline. 
They are located in the situations where intertrigo is liable 
to occur, such as the axilhe, groins, and where the scrotum 
comes in contact with the thighs. The latter situation is 
declared by Besnier to be nearly always the original site 
of the disease. From these favorite locations the disease 
may spread to the chest, abdomen, or thighs. Besnier 1 
met with a case involving the thigh down to the knee. 
The color of the patches is orange, red, yellowish, or 
brownish, or, in the folds of the skin, pale red. Their 
outline is sometimes marked by a raising of the epidermis. 
Their surface is dull-looking, and feels less smooth than 
normal and shows furfuraceous desquamation. They are 
quite tenacious, cannot readily be rubbec 1 off, and show 
little tendency to spontaneous recovery. There may be 
slight itching and a very little delicate sealing. 

Etiology. The disease occurs most often in men, and 
never in children. It is due to a parasite called the 
mierosporon minutissimum, which is described by Balzer 2 
as consisting of long wavy mycelia, that are rarely 

1 Jonrn. de Med. et ile Chirurg. prat,, 1883, liv., 351. 

2 Ann. de derm, et de syph., 1884, v., 597. 



EBYTHRODEBMIE PITYBIASIQUE. 265 

branched ; and of very fine spores. High powers of the 
microscope are necessary to see them. They are located 
exclusively in the corneous layer of the skin. He regards 
them as a common form of parasite that produces the 
disease in some people only on account of the peculiar 
fermentation of their skin secretions. 

Diagnosis. The disease resembles chromophytosis, 
eczema marginatum, and chloasma. It differs from 
chromophytosis in the darkness of its color ; in the 
absence of distinct, rather large scales that can be lifted 
by the nail ; in its location, sparing the trunk, except by 
extension ; and in the character of the microscopical 
appearances. From eczema marginatum it is distinguished 
by an absence of all inflammatory symptoms, by not being 
more pronounced at the periphery than at the center, and 
by the microscopical appearances. From chloasma it 
differs in being a parasitic and not a pigmentary disease, 
and in the change it causes in the feel and texture of the 
skin, and in the effect of treatment. 

Treatment. It is curable by the same means as is 
chromophytosis, namely, by the tincture of iodine ; pyro- 
gallol ; chrysarobin ; bichloride of mercury ; or sulphur. 
It is more obstinate than is chromophytosis, and quite as 
prone to relapse unless thoroughly eradicated. 

Erythrodermie Pityriasi<iue en Plaques Disseminees is the 
name given by Brocq to a relapsing eruption of the skin 
well described by J. C. White. 1 

It occurs upon the face, neck, trunk, and extremities 
in the form of irregular, circular or oval patches. These 
are not elevated. They are either smooth or scaly, the 
scales being small and thin, and seen only on close inspec- 
tion. Their color is red, which disappears on pressure. 
On the trunk they may have a brown tint. The diameter 
of the patches is from one-half to one and one-half inches. 
They fade out and disappear in warm weather, to relapse 
in cold weather. 

It differs from psoriasis in lacking the characteristic 
scaling of that disease and in not being infiltrated. From 
1 Journ. Cutan. and Gen.-Urin. Dis., 1900, xviii., 536. 



266 DISEASES OF THE SKIN. 

seborrhceal eczema it differs in the fineness of its scales and 
tlie absence of infiltration and itching. 
No treatment is availing. 

Erythromelalgia is a nervous disease characterized by 
the appearance of a persistent patch of congestion, often 
on the sole of the foot, attended with swelling and pain. 
(Foster.) 

Esthiomene. This is a disease of the vulvo-anal region 
that was described by Huguier, 1 and about which there is 
a good deal of uncertainty. It has been variously con- 
sidered as a form of lupus, syphilis, elephantiasis, and 
epithelioma. "It is characterized by a leaden or vio- 
laceous hue of the parts, and their simultaneous alteration 
of shape, induration, thickening, ulceration, destruction, 
hypertrophy, and infiltration, so that the orifices and 
canals of the vulvo-anal region may be at the same time 
ulcerated, enlarged, and constricted, and its grooves and 
cutaneous and mucous folds exaggerated, thickened, and 
the seat of more or less extensive and deep ulcerations and 
cicatrices; without pain, without directly threatening life, 
and for a long time without affecting the constitution." 
(Foster.) 

Farcy. See Equinia. 

Favus. Synonyms : Porrigo lupinosa, seu favosa, sen 
lavalis, seu scutulata ; Porrigophyta ; Tinea favosa, seu 
vera, seu ficosa, seu lupinosa, seu maligna; Trichomykosis 
or Dermatomycosis favosa; (Fr.) Teigne faveuse, teigne 
du pauvre ; (Ger.) Erbgrind ; Crusted or honeycomb ring- 
worm, Scall head, True porrigo. 

A contagious vegetable parasitic disease due to the 
Achorion Schoenleinii, and characterized by the presence of 
discrete or confluent, circular, pale sulphur-yellow cupped 
crusts, or by asbestos-like masses of grayish friable crusts; 
by loss of hair producing irregularly shaped, disseminated, 
red, bald patches; by permanent atrophy of the scalp; 
and by running a chronic course. 

Symptoms. Favus affects both the scalp and the non- 

1 Mem. de L'Acad. de Med., 1869, p. 507. 



FA VUS. 



267 



hairy skin as well as the nails and mucous membrane. 
We shall first describe it as it affects the scalp. A lesion 
of continuity, however slight, is probably necessary for 
contagion to take place. In a case of favus in a newborn 
child the period of incubation was found to be from six to 



Fig. 26. 




eight days. It begins either as one or more scaly erythe- 
matous spots ; or as minute yellowish puncta ; or as a 
group of vesicles smaller than those met with in ring- 
worm. These develop into small sulphur-yellow cupped 
crusts about the hairs. When the case is seen by the 
physician the early stage is usually passed, and he will 
1 G. H. Fox : Skin Diseases of Children. New York, 1897. 



268 



DISEASES OE THE SKIN. 



find that the hair is dry and lusterless, and has fallen out 
in places, leaving irregularly shaped bald patches, of all 
sizes, and of pronounced red color. Upon both the bald 
patches and the parts still covered with hair the sulphur- 
yellow cup- or saucer-shaped crusts will be found, with 
raised or rounded edges, and with one or several hairs 
growing out of the middle of them. There will be more 
or less scaling, and, if the disease be of some age, thick 
mortar-like crusts of grayish color. In some cases when 
first seen it may be impossible to find the characteristic 

Fig. 27. 




Favus of knee. 



crusts — scutula as they are called — they being obscured by 
the mortar-like masses. In some cases the scutula are 
wanting. If we approach near enough to the patient, Ave 
will appreciate a peculiar odor variously described as that 
of mice, straw, or of a menagerie. 

The crusts, or scutula, are situated about the hair 
follicles. They are from pinhead- to split-pea-size, accord- 
ing to age. At first they are covered with a thin layer of 
epidermis, but later the edges are free. When they are 



FA VUS. 269 

picked off they leave a moist depression which soon fills 
up, or a pustule, or an atrophied spot. The color is pale 
or sulphur yellow, or, if of long standing, it may be a 
dirty or greenish yellow. The crusts are discrete and 
disseminated or grouped ; sometimes they coalesce ; they 
are firm to the touch, and when crushed between the 
fingers impart a feeling of crumbling like mortar. There 
is a zone of slight redness about them. Though they 
may not be seen at the first examination, if the scalp is 
cleaned off and left to itself they will form in the course 
of two or three weeks. The baldness is rarely in well- 
defined patches. The patches may be few in number, or 

Fig. 28. 







Favus of hand, showing scutula. Side view. 

so numerous that the hair occurs only in islands. At 
first their color is inflammatory red ; later they become 
white and atrophic in appearance. The baldness is per- 
manent. The hair is dry from the first ; later it becomes 
brittle and splits longitudinally ; but it is never so easily 
broken as in ringworm, and can easily be pulled out with 
its roots. There is itching of the scalp. That is the only 
subjective symptom. Pustulation does not belong to the 
disease, but may be an accidental complication. Other 
complications that may arise are pediculosis, eczema, and 
enlargement of the cervical glands. 



270 



DISEASES OF THE SKTN. 



Occurring upon non-hairy parts favus undergoes mate- 
rially the same development and forms the characteristic- 
cups. Sometimes it will take the circular form of a 
ringworm with the development of vesicles, and resemble 
it very closely, only that the cups will be sure to develop 
somewhere. (Figs. 27, 28, and 29.) The scutula develop 
around the lanugo hairs. There may be only one patch 
of favus or a large part of the body will be covered by 
the fungous growth in the form of sulphur-yellow cupped 




Favus nf hand. Front view. 



crusts and asbestos-like masses. On the non-hairy parts 
the disease is easier of cure than on the scalp, and is not 
so apt to leave sears. In a single case, that of Kaposi, 
the favic fungus was found implanted upon the mucous 
membrane of the stomach. The nails may be affected, 
either in the form of onychitis beginning at the side of 
the nail, hardly distinguishable from the same disease de- 
veloped from common causes ; or in having a seutulum 
develop in the nail-bed and show through the nail. 



FA VUS. 271 

This is rare. The occurrence of favus upon the head 
will give a clue to the origin of the onychitis. 

Etiology. The disease is due to the implantation and 
growth of the Achorion Schoenleinii primarily in the scalp 
and secondarily in the hair. It is contagious, but not so 
much so as is ringworm. It used to be rare in New York 
City, but on account of its being constantly imported from 
Europe the disease is on the increase, and cases are begin- 
ning to occur in native Americans. Its course is very 
chronic, and it shows less tendency than ringworm does 
to spontaneous recovery about the time of puberty. 
Though children are more commonly affected than are 
adults, it is by no means uncommon to see it in full ac- 
tivity in people well advanced in life. It has been as- 
serted that the strumous diathesis predisposes to favus, 
but this is doubtful. Like all other parasites, it requires 
a certain soil upon which to grow, and does not affect all 
skins. It is a common disease in mice, and may occur in 
rabbits, dogs, cats, and fowls, and thus be a source of con- 
tagion for the human race. 

Pathology. The cups are composed almost wholly 
of the fungus, which consists of flat, narrow, branching 
and inosculating mycelial threads ^^q^ 1 °^ an mcn m 
diameter, and of pale-gray color ; and of small spores of 
round, oval, flask, or dumb-bell shape, and of a pale-green- 
ish color. (Figs. 30, 31.) The spores gain access to the 
skin by the orifices of the hair follicles, and, after remain- 
ing there undisturbed, begin to grow in the upper part of 
the hair sac, and between the superficial layers of the epi- 
dermis, and subsequently invade the hair, growing in its 
cortical substance. The cup may be formed either by the 
sinking in of the more central portion of the mass, or on 
account of the central portion being attached to the hair 
so firmly that it cannot so readily give way and bow out 
under the pressure of the growing fungus as do the parts 
farther away from the hair. The atrophy of the skin is 
largely due to the pressure of the growing fungus, which 
is powerful enough to destroy the cranial bones of mice ; 
and in part to the inflammation of the skin produced by 
the presence of the fungus. 



272 



DISEASES OF THE SKIN. 



The question of the unity or non-unity of the fungus 
of favus is still unsettled. Several fungi — Quincke says 
three, and Unna asserts that there are nine — seem capable 
of producing the clinical picture of the disease. Other 
competent bacteriologists hold that the apparently diverse 
fungi are either different stages of development of the 
same fungus or due to different culture-media. All varie- 
ties of the achorion produce the same clinical picture. It 
is distinct from the trichophyton fungus. 

Diagnosis. Most cases of favus are easy of diagnosis : 
the sulphur-yellow cupped crusts ; the asbestos-like gray- 
ish masses ; the red, atrophic bald spots, with tufts of dry 



Fig. 30. 




Achorion Schoenleinii. (After Kaposi.) 

and more or less kinky hair in them ; and the peculiar 
odor, being so well marked. Ringworm has none of these 
features. Moreover, it occurs in the form of circular, cir- 
cumscribed, only partially bald patches covered with gray- 
ish scales in moderate amount ; has characteristic nibbled- 
off " stumps " of hair ; and under the microscope we find 
the spores less abundant, smaller, and more uniformly 
round than in favus. It must be confessed, however, that 
without the clinical features of one or the other disease, 
none but a most expert microscopist could make the diag- 
nosis in a doubtful case by the microscope alone. In 
eczema baldness is very rare, and we will usually find a 
characteristic patch of the disease behind the ear ; its 



FA VUS. 



273 



crusts are greenish and tenacious, not gray and friable ; 
the hair is matted by the sticky exudation; and if dis- 
crete impetigo lesions are present, they will contain pus, 
and not be solid like the favus crust. Leaving the scalp 
alone for a time will decide the matter, as scutula will be 

Fig. 31. 




Achorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 

sure to form if the disease is favus. Seborrhea causes a 
general thinning of the hair, the scalp is not atrophic, 
there are no scutula, and no achorion in the hair and scalp. 
Lupus erythematosus resembles favus only in producing 
atrophic red spots. There will usually be patches of the 



274 DISEASES OF THE SKIN. 

disease elsewhere, and its whole course is different. Pso- 
riasis does not cause atrophic bald spots, and rarely occurs 
on the scalp alone. Alopecia areata presents more or less 
circular bald areas, but these are white, smooth, and of 
normal texture, and there is no fungous growth in the 
hair. Alopecia from syphilis in its secondary stage re- 
sembles favus more closely than any other disease of the 
scalp ; but it occurs primarily at a later age than does 
favus, it comes on more suddenly, there is no history of 
crusts, nor cicatricial alteration of the scalp, and there will 
be other evidences of syphilis on the body, and (especially 
in women) the broken arch of the eyebrows. 

Treatment. In the treatment of the disease we need 
three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling the 
hair out systematically from day to day, so that eventually 
all the hair of the scalp is plucked. To do this we may 

Fig. 32. 



Piffard's epilating forceps. 

use the epilating forceps (Fig. 32) ; or Kaposi's method 
of grasping the hair between the thumb and a spatula or 
piece of stiff cardboard held firmly in the hand ; or, in 
dispensary practice, we may employ epilating sticks, made, 
according to Bulkley, of 

R Cera; flavse, 3jj ; 

Lacca? in tabnlis, ^iv ; 16 

Picis burgundies, %x ; 40 

Gummi damar., §j ss ; 48 

These ingredients are to be melted together, and then 
moulded into sticks a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. 
When cold they are to be suddenly twisted off, when, of 
course, they will bring many hairs with them. The 
" calotte," or pitch-cap, used to be employed for this pur- 



FAVU& 275 

pose, but was given up because it caused the death of several 
patients. Kaposi's method is the best of all. If the head 
is greatly crusted, the crusts may be scraped off with a 
curette or cleaned off by means of soaking the scalp with 
oil for a day or two, and then washing with soap and 
water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil, with three per cent, of carbolic or 
salicylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent the 
spread of the fungus upon the scalp of the patient and to 
the scalp of other people. After the first washing we 
should allow the scalp to go unwashed for twenty-four 
hours, so as to permit the full action of the parasiticide. 

After the cleansing and the epilation the parasiticide 
must be rubbed and worked into the scalp. Of these, 
there are many from which to choose. Sulphur ointment 
is one of the best, if properly and persistently used. 
Other ointments are thymol, naphtol, resorcin, and pyro- 
gallol in five to ten per cent, strengths, and those of the 
ammoniate or yellow sulphate of mercury. Or solutions 
may be employed, as bichloride of mercury, two grains to 
the ounce of ether or alcohol ; the oleate of mercury or 
copper, ten to twenty per cent.; tar ; oil of cade ; creosote in 
ether or alcohol ; sulphurous acid in full strength ; sali- 
cylic acid, five per cent, in oil ; or tincture of iodine, or 
an ointment composed of a drachm of the crystals of iodine 
in an ounce of goose grease. Iodine, according to Sabou- 
raud, should be used only once a month ; in the meantime 
the scalp should be washed alternately with alcohol and 
camphorated alcohol, or with a solution of salol, one and 
a half per cent, and kept constantly anointed with iodine 
ointment. After a month the epilation and the iodine are 
to be repeated. Hydronaphtol plaster does good service 
in favus, used according to the method described under 
Trichophytosis, which see. Peroni ' recommends spraying 
the head with acetic acid used in an atomizer, after cover- 
ing any excoriated points with diachylon ointment on a 
piece of cloth. At first the scalp feels cold. Hyperemia 
follows, which lasts about forty-eight hours and disappears, 
1 Ann. de derm, et de syph., 1891, ii., 797. 



276 DISEASES OF THE SKIN. 

leaving slight desquamation. When the hyperemia 
lessens the acid is to he again used. When there are no 
excoriations the head is to be washed every morning and 
evening with water and corrosive sublimate soap. Busquet 1 
recommends sopping on daily a solution of 

R Essentia cinnamomi, 3ijss ; 101 

Spts. tether, sulph., ad |j ; ad 301 M. 

Besnier and Doyon 2 recommend as a preparatory treat- 
ment for favus that the hair be cut off from and around 
all the patches, and the whole head then covered for two 
or three hours with equal parts of soft-soap and lard. 
This is to be washed off with warm water, and the head 
is to be kept covered during the night with a cap of rubber 
or other impermeable cloth. The next morning the head 
is to be washed perfectly clean, bathed with a solution of 
boric acid (25: 1000), and covered with borated lint soaked 
in the following solution : 

R Sodii salicylati, ^iij ; 251 

Sodii bicarbonati, .^ijss; 10 

Aquae, ad Oij ; ad 10001 M. 

Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean, 
and then epilation must be practised, the hairs being pulled 
not only from the patches, but for about a half-inch about 
them. Epilation is to be repeated every week until no 
longer any trace of redness about the hairs exists, and the 
head is to be kept covered with the impermeable cap. 
Every evening the whole head is to be rubbed with an 
antiparasitic ointment, such as : 

R P>als. Pernv. vel 

Ol. cadini, 2 to 5 parts. 



aa 1 to 5 



Ac. salicyl., \ 

Resorcin., f 

Sulph. prsecip., 5 to 15 

Lanolini, ") 

Vaselini, > aa p. ae. ad 100 

Adepis, J 



Ann. de derm, et de syph., 1892, ii., 269. 

Kaposi: Mai. de la Peau, French ed., Paris, 1891. 



FEIGNED ERUPTIONS. 277 

Every morning the whole scalp is washed with tar soap, 
and each favic patch is soaked with the following : 

R Alcoholis (90 per cent.), 100 parts. 

Ac. acetic, (crystals), I to 1 part. 

Ac. boric, 2 parts. 

Chloroformi, 5 parts. M. 

Then each patch is to be accurately covered with mercurial 
plaster. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a para- 
siticide. 

Favus of the nail may be treated by the constant appli- 
cation of a mercurial, resorcin, or hydronaphtol plaster. 
If the disease is limited to one or two points, they may be 
cut down upon and the remedy applied directly. Some- 
times it may be necessary to remove the whole nail. 

After a case of favus has been faithfully treated for a 
number of weeks and looks as if it were well, it should be 
let alone and watched carefully for a long time. Any red 
point that appears is evidence that the disease is cropping 
up again, and should be immediately attacked. 

Pkognosis. The prognosis is good, provided the case 
is faithfully and energetically treated. Relapses will surely 
occur if any of the fungus remains in the scalp. A cure 
takes months or years to effect. The scars from favus 
are permanent. Favus of the nail is specially rebellious 
to treatment, and may cause permanent destruction of the 
nail. 

Feigned Eruptions. It is a good rule to consider the 
possibility of malingering whenever we meet with an erup- 
tion that does not correspond to any type eruption, and at 
the same time is not due to the action of drugs ingested or 
locally applied, nor to irritants that have come accidentally 
in contact with the skin. Eruptions are feigned mainly 
by three classes of individuals, namely, soldiers, sailors, or 
convicts for the purpose of shirking work; paupers for 
the purpose of gaining admission to hospitals ; and hysteri- 
cal young women for the purpose of exciting sympathy. 



278 DISEASES OF THE SKIN. 

Not only are feigned eruptions peculiar in appearance, but 
also it will be observed that they are usually on the left 
side of the body, as they are commonly due to acids applied 
by the right hand ; or on the legs. The back is seldom 
the seat of these lesions. Most commonly they are irri- 
tative lesions, such as would be due to tartar emetic oint- 
ment, croton oil, nitric acid, carbolic acid, mustard, and 
the like. If made by acids, the lesions will often have 
lines radiating from the main mass showing where the 
acid has run further than intended. Some of the lesions 
imitate genuine disease with amazing faithfulness. 

It is impossible here to give a full account of the feigned 
eruptions. A good list is given by Van Harlingen, 1 and 
to this I would refer the reader. Sycosis by tartar emetic 
ointment and tar; favus by means of acids; alopecia are- 
ata by means of plucking the hair; ringworm by means 
of depilatories ; scabies by means of excoriating with a 
fine needle ; various forms of ulcers and pustular eruptions 
by means of acids and caustics ; gangrene in the same way ; 
all these and others have been simulated. In case of a 
suspected feigned eruption the part should be covered with 
an impermeable dressing, when, of course, the lesions will 
soon be well. 

Feuergiirtel. See Zoster. 

Feuermal. See Nsevus. 

Fever Sore. See Herpes facialis. 

Fibroma. Synonyms : Fibroma molluscum ; Molluscum 
fibrosum; Molluscum simplex; Molluscum pendulum. 

Fibromata are soft tumors of the skin that are com- 
posed of a hyperplasia of the connective tissue as well as 
the subcutaneous tissue, and occur in various shapes, 
colors, and sizes. The most commonly encountered form 
of fibroma is 

Molluscum fibrosum. These may be of the color of the 
skin, or pinkish or even brownish or brownish red ; most 
commonly they are of normal color. They may be 

1 Morrow's Svstem of Gen.-Urin- Dis., Syph., and Dermat., vol. iii. 
New York, 1894. 



FIBROMA. 



279 



rounded, flattened, sessile, or pedunculated, but always 
raised above the level of the skin. They may hang down 
like polypi. The skin over them feels soft and of normal 
texture, or it may be thickened or atrophied. Hairs 
sometimes grow from them. There may be but one or 

Fig. 33. 




Multiple fibromata 



two present, or there may be hundreds of them so that 
the body is strewn over from head to foot with the vari- 
ously shaped tumors. The trunk is the most common 
location for fibromata, but they may occur on all parts 

1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. 



280 DISEASES OF THE SKIN. 

and involve even the mucous membranes. (Fig. 33.) 
They give rise to no inconvenience except on account of 
their size, which sometimes may be that of a child's head 
or larger. Their usual size is from that of a cherry to 
that of a walnut. Many of them show a slow growth, 
while many are stationary, and some may involute. Com- 
edones of large size may accidentally form in some fibro- 
mata. The larger ones may ulcerate. All of them feel soft, 
while the larger ones may be elastic to the touch. When 
they hang down in the form of large skin-folds which 
have undergone hypertrophy, the term fibroma pendulum 
is applied to them. Dermatolysis (which see) has been 
considered as a form of fibroma. According to some au- 
thorities, fibrous moles and soft warts are but forms of 
fibroma. 

Etiology. Fibromata usually appear in childhood, 
though they may not do so until 'later in life. They are 
sometimes hereditary, and are often seen in several mem- 
bers of the same family. They tend to increase with 
advancing age — that is, they are not so large or numerous 
in children as in adults. Children with multiple fibromata 
are often stunted both physically and mentally. By some 
authorities they are regarded as related to n euro-fibromata. 
Diagnosis. Molluscum fibrosum differs from molluscum 
contagiosum by not having a central depression, and by 
being of the normal color of the skin. They are also 
usually far more numerous. From fatty tumors they differ 
in not being tabulated, and in being pedunculated and less 
flat. Sebaceous cysts are not so numerous, and their con- 
tents can be squeezed out to a large extent, while fibromata 
are solid. 

There is another form of fibroma to which the name 
Acroehordon is applied. They occur as small, soft, pedun- 
culated, vascular, and mole-like lesions upon the face, 
shoulders, and elsewhere in elderly people whose skin is 
degenerated. They often take the form of little hernia- 
like sacs of skin when their contents have been absorbed. 

There is also a hard variety of fibromata called desmoids. 
These occur as round or oval, compact, smooth nodules, 
from hemp-seed to pea size. 



FOLLICULITIS. 281 

Treatment. They may be snipped off with scissors 
or tied off with ligature if pedunculated. If non-pedun- 
eulated, they may be destroyed by electrolysis or excised. 
If of large size, they must be excised. The galvano- 
cautery may be used to destroy any form. 

Fibroma Fungoides. See Mycosis fungoides. 
Fibroma Lipomatodes. See Xanthoma. 
Fibromyoma. See Myoma. 
Figwart. See Verruca. 
Finnen. See Acne. 

Fischschuppenausschlag. See Ichthyosis. 
Fish-skin Disease. See Ichthyosis. 
Flachenkatarrh der Haut. See Eczema. 
Flachenkrebs. See Epithelioma. 
Fleckenmal. See Nsevus pigmentosus. 

Flechten. May mean Herpes, or (nassende) Eczema, or 
(fressende) Lupus. 

Flea-bites occur in the form of small red puncta which 
may or may not be in the center of wheals. They some- 
times bear a close resemblance to urticaria that has been 
scratched. The grouped arrangement of the lesions and 
the limited areas upon which they occur suggest their 
origin. 

Flesh-worms. See Comedo. 

Fluxus Sebaceus. See Seborrhcea. 

Folliculitis means an inflammation of the hair follicles. 
When the hairs involved are those of the beard we have 
F. barbae, or sycosis, which see. The hair follicles on the 
extremities, especially of the legs, may become inflamed 
on account of some irritant applied to the skin. One 
form of this is tar acne. In workers in oil or paraffine it 
is no uncommon thing to see each hair on the legs, espe- 
cially the thighs, standing in the center of a red papule 
or pustule. The cure consists in removing the cause, in 



282 DISEASES OF THE SKIN. 

cleansing the parts, and the application of an alkaline 
soothing lotion. 

Folliculitis Decalvans. Under the name of folliculites 
d perifoUiciditex dicalvantes agminecs Brocq has described 
a form of inflammation of the hair follicle closely allied 
to sycosis. Besnier has given the same disease the name 
of alopecies ciccUrideUes innominfes. It is characterized 




Folliculitis decalvans. 



by an inflammatory process, which results in complete 
destruction of the hair papillae, and the formation of cica- 
tricial tissue; and by a tendency for its lesions to aggregate 
themselves in groups. Besnier 1 reported a case of this in 
1889. He says that it is the same thing that has been 
called acne lupoide and folliculite epilante. In the case 
reported the disease affected all the posterior part of the 
1 Ann. de derm, et de syph., 1889, x., 104. 



FOLLICULITIS DECALVANS. 283 

scalp, which was sown over with disseminated patches of 
baldness of unequal size, irregular shape, and serpiginous. 
They were depressed in the center, which was smooth, 
polished, thinned, cicatricial, and completely bald. Their 
borders were not well defined, but merged into the islands 
of healthy hair. The scalp between the borders and the 
center of the patches was bald, of variegated redness, with 
some hairs broken off at the surface of the scalp. In the 
funnel-shaped openings of the hair follicles there were little 
superficial collections of pus. Some of the patches were 

Fig. 35. 




Folliculitis decalvans. 

torn by scratching, and others looked precisely like those 
of alopecia areata, without signs of inflammation. All 
treatment seemed to be in vain, and the scalp bore only 
the mildest applications. 

Another variety of folliculitis decalvans is that described 
by Quinquaud. It affects most often the scalp hair, more 
rarely that of the beard, pubes, and axillary region. It 
produces irregularly shaped areas of baldness, which are 
quite smooth, polished, pale, atrophic-looking, and pre- 
senting at some points slight redness. The areas are 



284 DISEASES OF THE SKIN. 

disseminated, about the shape of a franc-piece, separated 
by islands of healthy hair. The bald spots are slightly 
depressed. At the peripheries of the patches or in the 
islands of healthy hair between them will be found pin- 
head, discrete pustules about the hairs. The latter are 
easily plucked or fall spontaneously. Or there are simply 
punctiform, isolated red spots which may or may not be 
scaly ; or a red, elevated, inflamed follicle. The fall of 
neighboring hairs produces the bald patches. The disease 
is very chronic and marked by a series of outbreaks. A 
micrococcus has been found in probable causative connec- 
tion with the disease. 

Still another form affects the bearded portion of the 
face, and from there invades the temporal region of the 
scalp. This is the ulerythema syeosiforme of Unna, and 
the so-called chronic sycosis. It begins like a sycosis, 
but when the inflammation subsides it is seen that the 
skin is cicatricial and the hair destroyed. There mav be 
one or more patches. The patches may be symmetrical 
or non-symmetrical, and they tend to spread slowly by 
peripheral extension. 

^ Treatment. The treatment found to be most effica- 
cious is to clean the scalp with soap and water ; to paint 
the diseased patches and their vicinage with the tincture 
of iodine ; and to bathe the same every morning with the 
following : 

R Hydrarg. biniod., gr. j; 15 

Hvdrarg. bichlor., gr. iv ; 1 

Alcohol., jjss ; 60 

Aquae destil., ad giv; ad 500 

This may check the disease, but the baldness is irremedi- 
able. (Brocq.) 

Folliculitis Rubra. See Keratosis pilaris. 

Fordyce's Disease of the Lips. In 1896 J. A. Fordyce 1 

first called attention to this disease, which is probably not 

very rare, as several other cases have been reported since 

then. It affects the mucous membranes of the lips in the 

1 Journ. Cutan. and Gen.Urin. Dis., 1896, xiv., 413. 



FUNGOUS FOOT OF INDIA. 285 

form of patches made up of small, irregular, closely aggre- 
gated milium-like bodies of light-yellow color, located just 
beneath the mucous membrane. These same bodies are 
also scattered disseminately about the patches. Burning 
and itching, and a feeling of tension as if the lip were 
swollen, are complained of. Similar lesions occur on the 
inside of the cheeks along the line of the closed teeth. 
These are somewhat lighter in color, more elevated and 
papillomatous. The milium-like bodies can be removed 
readily. They may be found in several members of the 
same family, and increase with age. They are atrophic 
sebaceous glands in the mucous membrane. 

Fragilitas Crinium. See Atrophia pilorum propria. 

Frambcesia. See Yaws and Dermatitis papillaris cap- 
illitii. 

Freckles. See Lentigo. 
Frieselausschlag. See Miliaria. 
Frostibite. See Dermatitis calorica. 

Fungous Foot of India. Synonyms : Madura foot ; 
Mycetoma ; Podelcoma ; Ulcus grave ; Tubercular dis- 
ease of the foot. 

This is a disease that is endemic in certain parts of India, 
but has been met with in this country. Though usually 
affecting the foot and leg, it is seen occasionally on the 
hands, shoulders, and scrotum. According to Crocker, 
there are two varieties, the pale and the black, the latter 
being the more common. It may begin with slight con- 
gestion of the affected part ; or as a local induration, either 
superficial or deeply seated, of some part of the foot, which 
is firmer, larger, more diffused, ^nd less painful than a 
boil. When this is opened, it discharges pus at first, later 
granules like poppy seeds, or mulberry-like masses are 
mingled with the discharge. Or it may begin as a black- 
ish or bluish mottled discoloration like tattoo puncta. The 
progress of the disease is slow, but in the course of a few 
years the foot becomes swollen and distorted, the arch 
being broken, the toes being over-extended, and the sole 
convex from behind forward. It becomes dotted over 



286 DISEASES OF THE SKIN. 

with the raised orifices of sinuses extending deep down 
into the tissues, and giving vent to the above-described 
discharge. 

It is more common in males than in females, and rare 
before puberty. Its origin is obscure, though it is supposed 
to be due to a fungus. Surgical interference is the only 
hope for a cure. 

Furunculi Atonici. See Ervthyma. 

Furunculus. Synonyms : (Fr.) Furoncle, Clou ; (Ger.) 
Blutschwar ; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation 
around a skin gland or hair follicle, characterized by one or 
more round, more or less acuminated, firm, painful forma- 
tions, and usually terminating by necrosis and suppura- 
tion. (Foster.) 

Symptoms. This is a common and familiar disease of 
the skin. Its most frequent locations are the back of the 
neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, pain- 
ful spot, which in two or three days enlarges to attain the 
size of a split pea or silver quarter- or half-dollar. It is 
now raised above the surface, hard, of a dark-red color 
at the center with the redness fading away into the sound 
skin, more or less pyramidal in shape, exquisitely tender 
to the touch, and with a most agonizing throbbing pain. 
Its center soon becomes yellow, indicating the point at 
which suppuration has taken place, and where it will 
open. From the opening comes the "core," a greenish- 
grav or whitish pultaceous mass mixed with pus and 
blood. With the escape of this all the symptoms subside 
and the cavity fills up by granulation, leaving more or 
less of a sear. The course of the individual boil is from 
seven to ten or fifteen days. At times suppuration does 
not take place, but the mass undergoes resolution. This 
is the so-called "blind boil." 

There may be but one boil or there may be hundreds 
of them. They come out in crops of from two to half 
a dozen at a time. If very numerous, or of large size, 
they give rise to constitutional disturbance. They may 



FURUNCULUS. 287 

continue to form for weeks, months, or even years, if left 
untreated. This is what is called furunculosis. 

Boils are always isolated. They may be confined to one 
locality or come out in a number of regions at the same 
time. There may be sympathetic enlargement of the 
neighboring lymphatic glands. If the disease is exten- 
sive, the patient presents a truly pitiable condition. 

If a boil starts from a sweat gland, it resembles that 
which originates in a sebaceous gland, except, according to 
Crocker, it has no mattery head and is somewhat less 
indurated. This form of boil is called hydradenitis 
by Yerneuil and Bazin. It is of the size of a pea, and is 
most often met with in the axillse, about the anus and 
perineum, near the nipples, and may form anywhere where 
there are sweat glands, excepting on the soles of the feet. 

Boils may occur in the external auditory canal in con- 
junction with the disease elsewhere. They are exceedingly 
painful and produce deafness. One or both ears may be 
affected, but usually it is only one ear. They may set up 
inflammation of the entire canal and tympanum ; one case 
of this sort has ended fatally. If the furuncle is situated 
in the posterior wall of the canal, or a general inflammation 
has been set up, considerable redness and tumefaction over 
the mastoid region may occur. (Dr. A. Hupp. 1 ) 

Etiology. The cause of furuncles is the entrance into 
the skin of the staphylococcus pyogenes aureus et albus. 
Local infection produces crops of boils occurring in one 
region, and the doctrine of local infection finds further 
support in the results of treatment by antiseptics. It 
must be remembered that these micrococci are widely 
distributed, having been found in dishwater, in the super- 
ficial layers of decayed vegetable matter, in the swaddling- 
clothes of healthy infants, in the dirt under the finger-nails, 
and in numerous other places. Like other parasites, these 
require some peculiarity of soil for their growth, or at 
least an opportunity for gaining entrance to the glandular 
apparatus of the skin. The soil is afforded in lowered 
vitality of the skin, and thus we find boils in diabetes 
mellitus, after specific fevers, in anaemia, lithsemia, uraemia, 
1 Personally communicated. 



288 DISEASES OF THE SKIN. 

and septicaemia ; and as a complication of other skin dis- 
eases, such as eczema, prurigo, lichen tropicus, and scabies. 
In many cases no disorder of the general health can be 
discovered. The second condition is fulfilled by local 
injury to the skin, such as friction or pressure, or scratch- 
ing. They are contagious, as well as auto-inoculable, and 
can be produced by inoculation of pure cultures of the 
micrococcus. The popular notion of their origin from too 
good living or from being run down is only another way 
of saying that they occur in individuals not in perfect 
health. 

Pathology. The inflammation begins in the corium 
and deeper tissues in or about the hair follicles or glands 
of the skin. " The mechanism of the process is supposed 
by some to be that the vessels around the gland or follicle 
become blocked, producing its death, and inflammation is 
then set up around the necrosed tissue to get rid of it by 
suppuration." (Crocker.) 

Diagnosis. The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. In many cases there is no need of inter- 
nal treatment. If the patient is out of health in any way, 
we should endeavor to help him back to his normal con- 
dition. In furunculosis we should always bear in mind 
the probability of there being diabetes mellitus at the 
bottom of the mischief, seek for it, and do our best to cure 
the patient if we find evidence of it. There are many 
drugs recommended for the treatment of boils, apart from 
constitutional conditions. Of these, sulphide of calcium 
is one of the most popular, one-tenth of a grain being 
given every two or three hours, or a fourth to a half-grain 
three or four times a day. It is of doubtful efficacy. 
Piffard speaks well of the compound syrup of the hypo- 
phosphites, a dessertspoonful three times a day. Hardy 
recommends tar-water up to a quart a day. The sulphite 
or hyposulphite of sodium in fifteen- to twenty-grain doses 
three times a day is also well spoken of. Yeast is a homely 
but sometimes efficient remedy, either a half-wineglassful 
being taken night and morning, or a like quantity in 



FURUNCULUS. 289 

divided doses, or one of Fleischmann's yeast cakes being 
eaten during the day. Le Gendre, 1 believing that boils 
may arise from the absorption of products of imperfect 
digestion, advises the disinfection of the intestinal tract by 
the use of the following powder : 



R /3-Naphtol, 

Bismuth, salicylat., |- aa gr. ivss ; 

carb., 



30 



which is to be given every four hours. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, 
the heat and moisture only facilitate the growth of the 
same and the production of new boils. That new boils 
are apt to spring up about a poulticed boil is a common 
experience. " Hands off" is the rule for young boils, nor 
should old ones be squeezed. We should endeavor to abort 
the development of a boil. To do this there are various 
approved methods, but the one most highly commended is 
the use of carbolic acid. This may be either by touching 
them with pure carbolic acid ; injecting them with a few 
drops of a two per cent, solution ; or spraying them with 
the same solution for fifteen minutes at a time eight times 
during the day, and keeping them covered with carbolized 
dressings in the meantime. Mercury may be used instead 
of carbolic acid, the boils being kept covered with emplas- 
trum hydrarg. with a little hole cut in the plaster to corre- 
spond to the center of each boil ; or an ointment of the 
nitrate or red oxide may be used. Painting with iodine 
is also commended ; as well as keeping them covered with 
a saturated solution of boric acid, or an eight or ten per 
cent, plaster or ointment of salicylic acid. Hardaway 
speaks highly of Unna's carbolic acid and mercury mull 
plaster. Electrolysis to destroy the follicle is spoken of 
by the same authority. 

When aborting is out of the question, it is a good plan 

to thrust a little pure carbolic acid, on the sharpened end 

of a wooden toothpick, or the like, into the central opening. 

It hurte for a few minutes only, and is promptly curative. 

1 Union med., 1888, xlv., 98. 



290 DISEASES OF THE SKIN. 

The boil should then be dressed with carbolized vaseline 
or a boric acid ointment, or a five per cent, salicylic acid or 
oil should be smeared over the boil and the contiguous 
parts. Or it may be opened and dressed with iodoform, 
or aristol, as the odor of the former is objectionable. Here 
too the mull plaster of carbolic acid and mercury maybe 
used. Instead of the pure carbolic acid, Crocker advises 
the glycerol e of carbolic acid of the British Pharmacopoeia. 

Furuncles of the car. My friend, Dr. A. Rupp, late 
aural surgeon to the New York Eye and Ear Infirmary, 
has kindly advised me on this head as follows : In the 
treatment of furuncles of the external auditory canal the 
first requisite is that the physician sees that which he is to 
treat. If the auditory canal be filled or unclean, it must 
be syringed out with a two to five per cent, solution of 
carbolic acid, followed by a solution of bicarbonate of soda 
as hot as can be comfortably borne. 

The canal is to be dried with absorbent cotton, and if 
the membrana tympaui is intact filled with 

R Hydra rg. bichlor. gr. v; [3 

Glycerini, 1 .. -. .. _J 

Alcoholis, j ^ 5J ! aa o0 M 

which is to remain in some minutes, and then the excess 
is allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. Protargol, five 
grains to the ounce of water, applied on pledgets of absorb- 
ent cotton and left in for an hour or two, gives good results. 
If the membrana tympani is deficient, the whole canal is 
to be filled with powdered boric acid and the orifice closed 
as before. In either case the cotton is to be changed when 
soiled. When furuncles are at the inner end of the canal 
near the membrana tympani, a leech or two in front and 
a little above the tragus will afford much relief. It is 
unnecessary to incise the furuncles except where pus has 
formed and has no outlet. 

Prognosis. In most cases boils are annoying, but not 
dangerous. Those about the face give the most trouble. 
How long new boils will continue to form it is impossible 



GOMMES SCBOFULEUSES. 291 

to say. If the treatment by carbolic acid is used, the dis- 
ease is usually soon over. In furunculosis all will depend 
upon how soon we can get the patient into a better phys- 
ical condition. 

Furunculus Orientalis. See Aleppo boil. 

Gale. See Scabies. 

Gangrene of the Skin. See Dermatitis gangrenosa. 

Gansehaut. See Cutis anserina. 

Gefassmal. See Nrevus vasculosus. 

German Measles. See Rubeola. 

Geromorphisme Cutane* is the name chosen by Drs. 
Souques and Charcot l to designate an affection that pro- 
duced changes in the skin of a girl eleven years of age so 
that she looked like an old woman. The expression of 
the face suggested that due to facial paralysis. The skin 
hung in loose folds, and was flabby like the skin some- 
times seen in very old people. Apart from loss of natural 
consistence and elasticity there was no change in the skin. 
If lifted up, twisted, or folded in any way, it returned 
very slowly to its normal position • and it was abnormally 
movable over the subcutaneous tissues, in these things 
suggesting that form of dermatolysis called "elastic skin."' 
There were no changes in the hair, nails, or teeth. There 
was no assignable cause for the condition, which was pre- 
served unaltered during an interval of ten years from the 
first to the last time that the doctors saw the case. 

Geschwiire. See Ulcers. 

Gesichtsatrophie. See Atrophoderma idiopathica. 

Glanders. See Equinia. 

Glanzhaut. See Atrophoderma idiopathica. 

Glossy Skin. See Atrophoderma idiopathica. 

Gneis. See Seborrhoea sicca. 

Gommes Scrofuleuses. See Scrofuloderma. 

^Nouvelle Iconographie de la Saltpetriere. 



292 DISEASES OF THE SKIN. 

Goose-flesh. See Cutis anserina. 
Granulationsgeschwulste. Connective-tissue new growths. 

Granuloma. This is a tumor consisting of granulation 
tissue. " Proud flesh " is of this nature. It is seen about 
wounds, such as that caused by vaccination. It is prob- 
able that there is some specific germ to cause the growth 
of these exuberant granulations. It sometimes takes the 
form of a raspberry. The application of nitrate of silver, 
tincture of iodine, or some antiseptic powder to it will 
cause it to flatten down speedily. 

Granuloma Fungoides. See Mycosis fungoi'des. 

Granuloma Necrotica. This is an affection whose true 
position is not finally determined. It has been described 
under various names, such as acnitis, hydrosadenitis sup- 
purativa destruens, granuloma innominatum, and necrotiz- 
ing chilblains. It consists, according to Johnston, in an 
eruption upon any part of the body of pale nodules in the 
subcutaneous tissues or deep in the cutis. They grow 
slowly and after a time approach the surface, when they 
are no longer movable, and their color changes to a rose or 
copper red. They now project above the surface. At first 
they are round, but later they become flattened, and finally 
depressed in the center as they become necrotic. They 
then show a central plug of dead tissue capped with an 
adherent crust that falls of itself or may be readily re- 
moved. A pit thus left after a time undergoes involution, 
and at last only a superficial atrophic scar remains. 

The disease is met with at all ages and in both sexes, but 
nearly all its subjects show signs of struma or tuberculosis. 
It is supposed to be caused by the toxin of tuberculosis. 
It bears a striking resemblance to a papular syphiloderm 
at one stage of its course, but may be distinguished by its 
slow course. Upon the fingers and toes it looks like chil- 
blains, but its necrotizing character distinguishes it. 

Grayness. See Canities. 

Greisenhaftigheit der Kinder. See Sclerema neonato- 
rum. 



HAARMENSCHEN. 293 

Grocer's Itch is eczema of the hand. 
Grubs. See Comedo. 
Grutum. See Milium. 
Grutzgeschwulst. See Atheroma. 

Guinea-worm Disease, or Dracontiasis, is met with en- 
demically in tropical climates. It is caused by the larvae 
of the guinea-worm, or filaria medinensis, being swal- 
lowed, and developing in the body, It is possible that the 
worm may gain access through a traumatism. The female 
makes its way into the muscles, and within nine or twelve 
months gives rise to the symptoms of the disease. The 
male probably dies and is passed out of the body. The 
symptoms of the disease are a small tumor under the skin 
that feels like a coil of soft string ; the appearance of a pea- 
to filbert-sized vesicle upon this when the animal is about 
to escape ; tension, pain, and itching ; in severe cases in- 
flammation, purulent discharge, hectic fever, and perhaps 
delirium. The worm is either gradually wholly extruded 
after the vesicle breaks, or a new tumor forms after a 
part has escaped, and this after a time breaks and the rest 
of the worm comes away. There may be only one worm 
or a legion of them. They are located most often in the 
foot, but may be found anywhere. 

Treatment. The treatment of the disease is to re- 
move the worm, which is done by winding it carefully 
around a stick when the head is protruded, giving a turn 
or two every day until the worm is extracted. Manson 
advises against this, and speaks well of injecting into the 
tumors a 1 : 1000 solution of bichloride of mercury. This 
kills the worm, and it can then be removed. Tincture of 
asafoetida in doses of one or two drachms three times a day 
kills the worm before extraction. 

Gumma. See Syphilis. 

Gune. See Tinea imbricata. 

Gurtelkrankheit. See Zoster. 

Gutta Rosea. See Rosacea. 

Haarmenschen. See Hypertrichosis. 



294 DISEASES OF THE SKIN. 

Haematidrosis, or Haemidrosis, is a rare disease of the 
sweat glands in which, on account of an effusion of blood 
into the coils and their ducts by diapedesis from the sur- 
rounding vascular plexus, blood is discharged upon the 
skin along with the sweat. The subjects are apt to be 
hysterical young women, though the affection has been 
seen in newborn children. It is in some cases vicarious 
menstruation. The points of election are the face, ear, 
umbilicus, hands, and feet. Ephidrosis cruenta and 
bleeding stigmata are other names for the curious malady. 
The treatment should be directed to the condition of 
the individual. 

Haemorrhcea Petechialis. See Purpura. 

Hair, Discolorations of. Hair sometimes falls out to 
grow in of a different color. The continuous hypodermic 
administration of pilocarpine has been followed by a 
change of color of the hair from light to dark. Green 
hair occurs in workers in copper ; blue hair occurs in 
workers in cobalt and indigo. These colors can be re- 
moved by washing. Yellow hair is occasionally seen in 
icterus. Various chemicals bleach the hair, such as 
peroxide of hydrogen. Chrysarobin stains it purple; 
resorcin may stain it green. Bicarbonate of soda changes 
dark hair to a dirty brown. 

Harlequin Foetus. See Ichthyosis congenita. 

Hautfinne. See Acne. 

Hauthorn. See Cornu cutaneum. 

Hautgries. See Milium. 

Hautkrebs. See Epithelioma. 

Hautsclerem. See Scleroderma. 

Hautwiirmer. See Comedo. 

Haemorrhage, Cutaneous. See Purpura. 

Haematrophia Facialis. See Atrophoderma idiopathica. 

Henoch's Disease. See Purpura fulminans. 



HERPES. 295 

Herpes. An acute inflammatory disease of the skin 
characterized by an eruption of one or more groups of 
vesicles upon reddened bases. 

There are two main varieties of the disease : one occur- 
ring upon the face, herpes facialis, and one occurring 
upon the genitals, herpes progemtalis. 

Fig. 36. 



>%?" #& 




Herpes febrilis. 



Symptoms. Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister, or cold sore, 
usually occurs upon the lower part of the face, about the 
mouth (Fig. 36). There is commonly some slight dis- 
turbance of the general economy, not as part of the dis- 
ease, but as the cause of it. The patient first notices 
more or less marked burning, stinging, or itching in the 
part, and perhaps at the same time erythematous papules 



296 DISEASES OF THE SKIN 

may form. After a few hours a number of pin head- to 
pea-sized, clear, fully distended vesicles will appear upon 
an erythematous base. Perhaps the herpetic patch may 
appear suddenly without antecedent erythema. There is 
usually not more than one or two patches of small size. 
There may be a score or more of them, and they may be 
of large size. The patches are always irregular in shape. 
There may be but two or three vesicles in a group, or 
there may be a dozen of them. They do not tend to 
break down of themselves, but after a few days dry up 
into a crust which falls and leaves a red spot that soon 
disappears. Sometimes the vesicles may coalesce into 
bullae, the covers of which may fall and a superficial ul- 
ceration be left. The duration of the disease is about 
eight or ten days. The most common location is upon 
the upper lip, but it may be anywhere upon the face, and 
not uncommonly the groups develop bilaterally. The 
mucous membrane of the mouth may also be involved, 
but here, owing to the heat and moisture, the vesicles are 
seldom seen, as they break down and leave excoriated 
points. There is a strong tendency for the disease to 
recur with the recurrence of the exciting cause. In some 
cases it recurs at irregular intervals for months and with- 
out apparent cause. 

Etiology. It is still an undetermined question whether 
herpes facialis is a zoster or not. By most authorities it 
is considered to be an independent disease ; by a few it is 
thought to be an incomplete zoster. It is known to occur 
with catarrhal inflammations of mucous membranes, such 
a.3 a coryza or bronchitis; with digestive derangement, as 
gastritis or enteritis; with various febrile diseases; and 
it is very often seen in women as a herald of the menstrual 
epoch, occurring with great regularity for years. It arises 
sometimes on account of an injury to the terminal ends of 
the nerves, and, as such injuries are liable to occur in the 
tender mucous membrane of the lips, this may be an ex- 
planation of its frequency about the mouth. Infection has 
been invoked by a few observers as a cause, but this is 
not proven. It is evidently a neurosis, and in some cases 
no cause for it can be found excepting nerve disturbance. 



HERPES. 297 

Sometimes it occurs coincidently with herpes progenitalis 
or with zoster. 

Diagnosis. It must be diagnosticated from zoster and 
from vesicular eczema. From zoster it differs in not oc- 
curring in a series of groups scattered along the course of 
distribution of the trigeminus ; and in frequently being 
bilateral. Generally speaking, there is more marked 
neuralgia in zoster, though in some cases this is wanting. 
From eczema it differs in the large size of its vesicles, in 
their showing no tendency to break down, in being less 
pruriginous, in running a regular course, and in rapidly 
recovering by the simple drying up of the vesicles. 

Treatment. Left to itself the disease Avill speedily 
get well, and really requires no treatment beyond protec- 
tion with flexible collodion or any indifferent soothing 
lotion or ointment. We are often asked if wc cannot 
prevent or abort the disease when due to the menstrual 
flux. Women know well that the application of spirits 
of camphor will sometimes do this. Hardaway recom- 
mends rubbing the parts with borax. One of the alco- 
holic solutions recommended by Leloir for this purpose in 
herpes progenitalis may be used, namely, either two per 
cent, resorcin ; one per cent, thymol ; three per cent, men- 
thol, or two per cent, tannin frequently applied. 

Herpes progenitalis. This has been called herpes prse- 
putialis, but as it occurs in women as well as men and on 
other places than the prepuce, that name is obviously in- 
correct. 

Symptoms. The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 
upon an erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear with 
serous contents, and if on moist locations, as under the 
prepuce or about the mucous membranes of the female 
genitals, they soon break down and leave tiny excoria- 
tions. There may be but one or several patches of herpes. 
The disease runs a course of eight or ten days and gets 
well of itself, unless irritated under the mistaken idea of 
its beinff a soft sore. 



298 DISEASES OF THE SKIN. 

According to Bergh, 1 who has made a careful study of 
the disease, in women the groups usually contain five to 
eight pinhead- to hemp-seed-sized vesicles, but may have 
twenty to thirty-five millet- to poppy-seed-sized vesicles. 
Around each group is a reddish areola. The vesicles are 
isolated, and seldom confluent. Itching is apt to precede 
their outbreak. There may also be slight tenderness or 
swelling of the neighboring glands. In both sexes the 
patches may be unilateral, bilateral, or median. In men 
it occurs most frequently on the inner surface of the pre- 
puce, then on its outer surface, the sulcus, glans, meatus, 
sheath of the penis, and rarely in the meatus. In women, 
Bergh found it most often on the labia majora, then the 
labia minora, and genito-anal region ; seldom on the clitoris 
or in the vestibule ; very rarely on the cervix uteri. 
Unna 2 gives the order of frequency as labia minora, 
clitoris, labia majora, introitus vagina? ct carunculse nivrti- 
formes, perineum, anal region, gen i to-crural fold, mons 
veneris, and mucous membrane of anus and vagina. The 
disease has a tendency to relapse, in men with each coitus, 
in women with each menstrual period. It is common in 
women to have herpes of the face at the same time, and 
this has been noted in men. In women herpes facialis 
may occur with one menstruation, and herpes progenitalis 
with another. 

Etiology. The cause of the disease is congestion of 
the genital region. Thus in men it is frequently <qou two 
or three days after each coitus; or accompanying a gonor- 
rhoea or chancroid. A long prepuce seems to predis- 
pose to it. In women it conies in eighty per cent, of the 
eases with menstruation (Bergh), and in them it does not 
seem to have any marked relation to the sexual act. 
It is also seen in connection with pregnancy and the puer- 
peral state, as well as in gout, constipation, and digestive 
disorders. It is a not infrequent disease. Greenough 3 
met with it in men in about seventeen per cent, of all 
venereal cases in private practice. In women there are no 

1 Monatsliefte f. orakt. Dennat., 1890, x., 1. 

2 Joum. Cutan. and Yen. Dis., 1883-4, i., 321. 

3 A roll. Dcrraat., 1881, vii., 1. 



HERPES. 299 

statistics from private practice, and, indeed, it is in this 
country but rarely reported. Both Bergh and Unna, how- 
ever, met with it very frequently in public prostitutes in 
St. Petersburg and Hamburg. 

Diagnosis. The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic stand- 
point on account of its liability to be taken for chancroid 
or for the initial lesion of syphilis. This can hardly occur 
if the vesicles are seen, but when they are no longer pres- 
ent some difficulty may arise. From chancroid the super- 
ficial character of the lesions and their grouping point 
to herpes. In case of doubt the use of a simple dust- 
ing powder for a day or two will clear up the difficulty, 
because the chancroid will continue to enlarge while the 
herpes will become well. Auto-inoculation will afford 
positive evidence. From the initial lesion of syphilis 
herpes differs in the absence of all induration of its base 
and in the inflammatory character of the lesion. Here 
again a short wait will clear up the diagnosis. 

Treatment. Herpes progenitalis will usually promptly 
disappear by the use of a dusting powder of bismuth, or 
oxide of zinc and starch ; or by covering it with a piece of 
lint soaked in an astringent solution, such as a weak lotion 
of liquor plumbi subacetatis. If suppuration has occurred 
on account of bad treatment, and the glands are enlarged 
or tender, the patient had best be put in bed. Circum- 
cision has been recommended to prevent recurrences, but 
is of doubtful efficacy. It is well to have the patient wash 
the parts daily and after coitus. Marriage and fidelity to 
the wife are good means of curing a relapsing herpes. 
Astringent washes are useful in both sexes. If the 
"habit" of herpes progenitalis, as it may be termed, has 
been formed, careful hygienic and general treatment may 
be necessary for a cure. Leloir's directions, as given 
under Herpes facialis, may be tried for aborting the disease. 

Herpes Circinatus is either erythema iris or trichophytosis 
corporis. 

Herpes Circinatus Bullosus was the name given by Wilson 
to what has since been called Herpes gestationis. 



300 DISEASES OF THE SKIN. 

Herpes Cretace. Sec Lupus erythematosus. 

Herpes Esthiomenes. See Lupus vulgaris. 

Herpes Gestationis is regarded as being a dermatitis her- 
petiformis occurring during and provoked by pregnancy. 
It is prone to relapse with each succeeding pregnancy; and 
slowly subsides after delivery. Apart from its etiological 
relation, it corresponds closely to dermatitis herpetiformis, 
which see. 

Herpes Imbrique. See Trichophytosis corporis. 

Herpes Iris. See Erythema iris. 

Herpes Parasitaires. See Trichophytosis corporis. 

Herpes Phlyctaenoides. See Zoster. 

Herpes Tonsurans, seu Tonsurant. See Trichophytosis 
capitis. 

Herpes Tonsurans Maculosus. See Pityriasis rosea. 

Herpes Zoster. See Zoster. 

Herp^tide Maligne Exfoliative. See Dermatitis exfolia- 
tiva. 

Herp^tide. This is a class of skin disease which depends 
upon what the French writers call the herpetic diathesis. 
The affections in this class are marked by long duration, 
obstinacy to treatment,' tendency to relapse, and more or 
less pain and discomfort. Under it are included eczema, 
the lichens, psoriasis, and prurigo. 

Hidrocystoma. This disease was formerly regarded as a 
pompholyx of the face, but Robinson 1 has shown that it is 
a separate affection. 

Symptoms. The eruption occurs upon the face in the 
form of a large number of discrete, disseminated, tense, 
clear, watery, boiled-sago-grain-like vesicles. In size they 
vary from that of a pinhead to that of a pea. In color 
they may be light yellow, of a bluish tint, or white. If 
pricked, a drop of clear acid fluid escapes. They are 
obtuse, round, or ovoid. If they are present in immense 

1 Jonrn. Cutan. and < un.-Urin. Dis., 1893, xi., 29:5. 



HIDROCYSTOMA. 



301 



numbers, they may crowd closely together, but do not 
coalesce. There is no sign of inflammation about them, 
and no subjective symptoms arise from them, excepting, at 
times, a feeling of tension or smarting that is not pro- 
nounced. After lasting several weeks they dry up and 
disappear, while new ones appear. 

Fig. 37. 





Hidrooystoma. 



The eruption is usually seen upon the lower part of the 
forehead, the orbital region, nose, cheeks, lips, and chin — 
that is, upon the middle regions of the face. 

Etiology. The disease occurs most often in women, 



302 DISEASES OF THE SKTN. 

and especially in washerwomen. It occurs also in men. 
I have seen one or two cases in grooms. It is worse in 
summer, often disappearing entirely in winter, to return 
in the following summer. It is a disease of adult life. 

Pathology. The secreting portion of some of the 
sweat glands has an enlarged lumen from dilatation of the 
tube and contraction or compression of the epithelial cells 
against the basement-membrane, the lumen being filled 
with liquid, and a granular material resembling that usually 
seen in normal glands, but in increased amount. With 
the exceptions of those thus affected, the excretory appara- 
tus is normal. (Robinson.) 

Treatment. As far as possible the patient must avoid 
everything that will cause sweating. The individual lesions 
must be punctured. 

Hirsuties. See Hypertrichosis. 

Hives. See Urticaria. 

Homines Pilosi, seu Sylvestris. See Hypertrichosis. 

Honeycomb Ringworm. See Favus. 

Horn. See Cornu cutaneum. 

Huhnerauge. See Clavus. 

Hyalome Cutane. See Colloid degeneration of the skin. 

Hydrosadenitis Suppurativa Destruens. See Granuloma 
necrotica. 

Hydradenomes Eruptifs. See Adenoma of sweat glands. 

Hydroa is practically dermatitis herpetiformis. It is an 
old term recently revived, and is of uncertain significance. 
By some it is used to designate eruptions that are midway 
between erythema multiforme and pemphigus. As derma- 
titis herpetiformis certainly comprises what has been de- 
scribed as hydroa, I shall consider the latter no further. 

Hydroa Bulleux. See Erythema iris. 

Hydroa Vacciniforme. Hutchinson, under the name of 
" Recurrent Summer Eruption," Unna, under the name of 
" Hydroa Puerorum," and Bazin, under the name at the 



HYPERESTHESIA. 303 

head of this section, have described a bullous disease that 
occurs mostly in boys and upon exposed parts. It may 
occur on covered parts. It usually occurs in summer, and 
then seems to be due to the heat of the sun. It may occur 
in winter, and be due to the action of high winds. It is a 
symmetrical disease. The bullae form as such or as the 
result of the confluence of vesicles, and commonly both 
vesicles and bullae are present at the same time. The 
vesicles are prone to become depressed in the center and 
resemble vaccine scars. Scarring is apt to result. Usually 
there is no itching, but pain or burning. The disease 
recurs from time to time, the relapses at times being so 
frequent as to render the disease almost continuous, and 
tends to cease altogether as puberty is reached. The disease 
is related clinically to bullous erythema and to dermatitis 
herpetiformis, though it differs from them in leaving scars. 
Bowen has shown that it is inflammatory in origin. 

The treatment is not very satisfactory. The exposed 
parts should be protected as much as possible from the 
action of the wind and sun by means of veils or a calamine 
lotion. If bullae form, they must be treated as in pem- 
phigus. 

Hygroma Cysticum Colli Congenitum. See Lymphan- 
gioma. 

Hyperesthesia. This is that condition of the skin in 
which pain is experienced on the slightest contact even of 
a current of air, in this differing from dermatalgia, in which 
the pain is spontaneous. When the sense of pain is exag- 
gerated while the sense of touch is lessened, it is called 
Hyperalgesia. The hypersensitiveness may be for cold 
only, or for heat only, which is not so common. It is a 
neurotic disease, and is met with most commonly as a 
symptom of other diseases, such as non-tubercular leprosy, 
hydrophobia, and hysteria. Idiopathic cases are met with, 
though rarely. The hyperaesthesia may be general or 
localized, unilateral or symmetrical. 

The treatment is in most cases that of the disease of 
which it is but a symptom, and belongs rather to the 
domain of the neurologist than to that of the dermatologist. 



304 DISEASES OF THE SKIN. 

Hyperidrosis. Synonyms : Ephidrosis ; Idrosis ; Suda- 
toria ; Polyidrosis ; Excessive sweating. 

A functional disorder of the sweat glands characterized 
by an excessive flow of sweat. 

Symptoms. Hyperidrosis may be general or localized ; 
unilateral or symmetrical; in large or small amount. The 
cases of general sweating occur most often symptomatically 
in the course of general diseases, such as phthisis, malaria, 
and rheumatism, and do not concern us now. Some cases 
occur idiopathically. Such patients are usually fat. The 
hyperidrosis may be constant or at intervals, being excited 
by the slightest irritation of the nervous system, or by 
muscular exertion. The outburst of the sweat is generally 
preceded by a prickling sensation. It is often accompanied 
by prickly heat (lichen tropicus). 

We are called upon as dermatologists to treat localized 
sweating more often than the just-described variety, and 
such cases occur most commonly upon the palms and soles, 
in the axillae, about the genitals, and on the face and scalp. 
The excessive flow of sweat may be constant ; but it is 
usually paroxysmal, and often under the influence of the 
emotions. It is usually more pronounced in warm than 
in cold weather. Fat people are more prone to it than 
are those who are thin ; anaemic and delicate people rather 
than the robust. In some cases there may be a sense of 
tingling before the flow occurs. The affected part may be 
warm or cold ; if the first, it is apt to be somewhat hyper- 
semic. Occurring in places that are warm and covered, 
bromidrosis is a common accompaniment. The disease 
may last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweating is only enough to keep them 
more or less constantly moist ; sometimes it is so abundant 
as to drop from the hands and fingers, or even to fill up the 
hollow of the upturned palm and run over the edge. It 
spoils gloves, and interferes with many forms of work. 
Sweating soles are soon followed by tender feet, the epider- 
mis becoming sodden, macerated, and removed. It inter- 
feres with walking. The edge of the foot just .about the 
soles appears as a white or gray line or seam of sodden epi- 



HYPERWROSIS. 305 

dermis with a pinkish seam above it. The sodden appear- 
ance is also well marked between the toes. Sweating in 
the axillae spoils the clothing, and is only rendered worse 
by the rubber dress-shields so commonly worn by women. 
In its paroxysmal form it is frequently encountered in 
patients stripped for examination in public. This form 
has been aptly named by the French the " military sweat," 
as it is seen so often in examining recruits for the army. 
Sweating about the genitals is often accompanied by in- 
tertrigo, which may also occur in other parts subject to 
hyperidrosis where folds of skin are in contact. Sweating 
of the face is most commonly encountered upon the fore- 
head, nose, and eyelids, beads of sweat standing out upon 
them or running off in little rivulets. It is here that 
hsemidrosis is most common. Upon the scalp it has been 
observed that its occurrence is frequently followed by loss 
of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead, face, or whole body. Upon 
the forehead and face this form of sweating occurs as an 
accompaniment of migraine and limited to the painful re- 
gion ; it is in paraplegia that one-half of the body alone is 
affected. Kaposi l has reported one case of hyperidrosis 
affecting only the upper half of the body. 

Etiology. The disease is probably due to a disturb- 
ance in the sphere of the sympathetic system. It has 
followed lesions of the cerebro- spinal nerves. It occurs 
in all classes and conditions of men, and in all ages and 
both sexes. In some cases it is hereditary. Ill health 
seems to be the cause in many cases ; it may be anaemia ; 
chlorosis ; lithsemia ; hysteria ; or general debility. In 
any case it is purely a functional disease of the sweat 
glands, they being structurally unchanged. 

The diagnosis is so evident that we need not stop to 
differentiate it systematically. 

Treatment. The condition of the patient's health is 

to be carefully investigated, and tonics, mineral acids, mix 

vomica, or other medicine ordered according to the nature 

of the case. If there is no indication for this plan, or it 

1 Arch. f. Dermat. u. Syph., 1899, xlix., 321, 

20 



306 DISEASES OF THE SKIN. 

does not succeed, recourse may be had to belladonna or 
atropia to the point of producing their full physiological 
effect ; or pilocarpine one-twentieth grain, three times a 
day ; or agaricin in doses of one-sixth grain ; or ergot half 
a drachm of the fluid extract three times a day. Crocker 
has found a full teaspoonful of precipitated sulphur in milk 
twice a day the best remedy. If it loosens the bowels too 
much, he prescribes it as follows : 



& Pulv. crette co., 


3'ij ; 


25 


Pulv. cinnaru. co., 


3>j; 


15 


Sulph. praecip., 


5J; 


100 


Sig. A teaspoonful twice a day. 







The local treatment of sweating hands and armpits in 
many cases is as unsatisfactory as the constitutional treat- 
ment. There have been many plans proposed. Local 
faradization is one agent. Very hot water may be sponged 
on for a few minutes ; belladonna ointment or liniment 
may be rubbed in ; or we may use some astringent applica- 
tion, as of subnitrate of bismuth, tannin, alum, sulphate 
of zinc, borax, and the like, in alcohol, ointment, or pow- 
der. As a rule, ointments cannot be used on the hands 
and face. The most reliable of these is probably a satu- 
rated solution of boric acid, or a three per cent, solution 
of salicylic acid. Kaposi speaks highly of the good effect 
of bathing the parts with a five per cent, solution of naph- 
tol in alcohol, and keeping them powdered with one part 
of naphtol to one hundred of starch. Piffard recommends 
freshly prepared silicic hydrate, one part, in cold cream, 
nine parts. Sulphate of quinine, five per cent, in alcohol, 
may be tried. For sweating of the feet the best means 
are those given under Bromidrosis, which see. Perman- 
ganate of potash in one per cent, strength may be used. 
Unna recommends ichthvol in two and one-half per cent, 
ointment and the use of ichthyol soap. Formalin has its 
advocates. P. Richter 1 advises sprinkling tartaric acid 
between the toes and in the stockings for sweating of the 
feet ; and painting with a ten per cent, solution of chromic 
acid every five days for sweating of the hands. 
^Allg.Med. Centr.Zeit., 1897, lxvi., 927. 



HYPERTRICHOSIS. 307 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hyperkeratosis Excentrica. See Porokeratosis. 

Hypertrichosis. Synonyms : Hirsuties ; Trichauxis ; 
Polytrichia ; Dasyma ; Trichosis hirsuties ; (Fr.) Poils 
accidentels ; Superfluous hair. 

Symptoms. Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, nor- 
mally, only lanugo hairs, are present. It may be general 
or partial, congenital or acquired. The general form is 
also congenital, but it is never universal, as no hair grows 
upon the palms and soles, the backs of the last phalanges 
of the fingers and toes, the inside of the labia majora, the 
prepuce, and glans penis. Subjects of this malady are 
usually born covered more or less thickly with hair, which 
may be light or dark in color. This continues growing 
longer, coarser, and darker till it reaches its full develop- 
ment. As a rule, the long hair covering the body is fine, 
resembling more the hair of the head than that of the 
beard, as is also the case with the hair on the face of these 
people. With this excessive growth of hair there is 
usually combined a deficiency of teeth, specially marked 
in the upper jaw. Subjects of this malady are called 
homines pilosi, and are met with in all quarters of the 
world. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nsevus. The distinction between a localized 
hypertrichosis and a nsevus is made mostly upon the color 
of the underlying skin. In the former case the skin is 
perfectly normal, while in the latter it is pigmented and 
may be otherwise altered. These localized and partial 
cases of hypertrichosis are most frequently met with in 
the sacral or lumbar region, and not infrequently are asso- 
ciated with spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an ex- 
cessive growth of hair in regions where it is usually found, 
or of the development of hair in regions usually hairless or 



308 DISEASES OF THE SKIN. 

provided only with downy or lanugo hair, or of the devel- 
opment of pubertal hair at an early age. 

The following cases are instances of excessive growth 
and precocious development. Chowne ' speaks of a boy, 
eight years of age, who had the whiskers of a man. Beigel 2 
has seen a six-year-old girl with pudenda like a twenty- 
year-old woman, both in shape and hair. A case of 
excessive growth was met with by Leonard 3 in a man 
whose beard measured seven feet six and a half inches in 
length. Other instances of excessive length of beard 
are found in medical literature. 4 Many men have an 
excess of hair upon the chest and shoulders. Hair is 
generally better developed upon the forearm than upon 
the upper arm, and upon the legs than upon the thighs. 
As men grow old they are apt to have long hairs grow 
from the nostrils and the ears. These are instances of 
the growth of strong hair where normally only lanugo 
hairs are present. 

The growth of the beard in women is the form of hyper- 
trichosis which concerns us most, as it is the deformity 
which we will be called upon to cure. As women grow 
old, especially after they have passed through the climac- 
teric period of middle life, a slight mustache or a few 
straggling dark hairs on other parts of the face often 
appear. These growths seldom annoy them much, as they 
are accepted as evidences of advancing years. The case 
is very different when a young woman is afflicted with a 
beard, and most of the patients who apply for relief from 
their facial hair are between twenty and thirty-five years 
old. In them the hair generally begins to grow so as to 
be noticeable at about the eighteenth year of age. To get 
rid of the trouble the tweezers are first resorted to; then 
depilatories are tried ; sometimes burning is attempted, 
and as a final refuge a razor is used. All the time the 
hair grows coarser and more abundant. Some of these 
women shun company, keep themselves shut up all day, 
their health deteriorates, and, constantly brooding over 

1 Lancet, 1852, i., 421. 2 Virchow's Archiv, 1808, xliv., 418. 

3 The Hair: its Diseases and Treatment. Detroit, 1881. 

* Jackson: Diseases of t lie Hair and .Scalp. New York, 1887. 



HYPERTRICHOSIS. 309 

their misfortune, they are prone to become hypochondriacal 
and melancholic. The amount of hair present in these 
cases varies. Perhaps the commonest growth is the mus- 
tache alone. In most of my cases the hair has grown 
thickest and coarsest under the chin and upon the front of 
the throat. It is rare, even in the best developed cases, 

Fig. 38. 




to have much hair under the lower lip. Sometimes the 
growth is as complete, as heavy, and as coarse as is met 
with in men. The skin in many cases is coarse, muddy, 
greasy, and studded with acne. 

From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
1 By the courtesy of Dr. S. Dana Hubbard. 



310 DISEASES OF THE SKIN. 

treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and 
warm. In some of these cases the increase is probably 
more apparent than real, the hair not having been rubbed 
off by friction. Likewise, after injury to nerves the hair 
sometimes becomes hypertrophied, only to fall out after 
recovery. Continued irritation of a part, as by blisters, 
may stimulate hair-growth which may or may not be 
transitory. The most interesting of this group of cases 
is that comprising those of hirsuties occurring during 
pregnancy and disappearing after some months. Wilson 
reported a case of delayed appearance of menstruation in 
which hair grew upon the face. After the menstrual func- 
tion was established the hair ceased to grow and gradu- 
ally disappeared. 

Etiology. The cause of hypertrichosis is very obscure 
in some of its forms, while in other varieties we can more 
readily discover it. In general congenital hirsuties heredity 
plays an important part. But hereditary tendencies will 
not explain the first appearance of these congenital cases. 
Virchow endeavored to account for them upon the theory 
of nervous influence, founded upon the fact that in the 
Kostroma people — a markedly hairy father and son — the 
lack of development of the teeth and jaws was in the same 
zone as the over-development of the hair on the forehead, 
nose, cheek, and ears ; these regions all being supplied by 
branches of the trigeminus or fifth cranial nerve. Unna's 
theory of congenital hypertrichosis is that it is due to a 
persistence of the foetal or primitive hair ; the change of 
type between the primitive and permanent hair not taking 
place. 

The cause of acquired hirsuties is, in some cases, not far 
to seek. Heat and moisture will apparently increase the 
growth of hair, just as they favor the growth of vegetable 
life. Thus the hair has grown luxuriantly under the stim- 
ulation of poultices, and on the limbs when confined in a 
fracture-box. To these factors must be added an increase 
of the flow of blood to the part. Increase of the flow of 
blood will stimulate hair-growth independently of heat 
and moisture. At least Prentiss's ease of hair growing 



HYPERTRICHOSIS. 311 

more luxuriantly and coarser under the use of pilocarpine, 
which causes hyperemia of the skin, would seem to indi- 
cate this. Hypertrichosis following injury to nerves is 
probably dependent upon vasomotor disturbances. The 
growth of hair upon exposed parts, as upon the arms and 
chest of laboring-men, sailors, and the like, is due to the 
local irritation of the sun and wind. 

Now we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with derange- 
ment of the uterus and appendages. Because in some 
bearded women there has been some evident derangement 
of the sexual organs, it has been affirmed that some similar 
derangement is present in all. This is on a par with the 
too loosely accepted idea that the too free use of alcohol is 
the only cause of rosacea. In the cases I have met with, 
the majority were as free from uterine trouble as the rest 
of their sex. While it is true that some of these women 
are of masculine build, and have a masculine voice, most 
of them do not exhibit these characteristics. In some 
cases, however, there does seem to be some relation between 
the reproductive organs and the growth of the beard. 
Heredity is well marked in the majority of cases. It is 
improbable that attempts at destroying the fine hair cause 
the development of the coarse hair. It is more likely that 
they only strengthen its growth. Women are prone to trace 
the appearance of hair on the face to the use of vaseline, 
cold cream, and the like. There is no scientific founda- 
tion for this. 

An interesting study of the relation between hirsuties 
in women and insanity was made by Hamilton. 1 He re- 
gards hair-growth on the face in women as the inevitable 
result of the over-active and continuous exercise of the 
uterine and ovarian functions. He believes it to be of 
neuropathic origin, connected with disorders of the fifth 
cranial nerve ; and that when it occurs upon the face of an 
insane person it is indicative of an unfavorable form of in- 
sanity, especially if the subject has not reached middle life. 
1 Med. Rec, 1881, xix., 281. 



312 DISEASES OF THE SKIN. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way : While at times there appears to be 
a relation between the uterine, or, more properly, the 
menstrual function, and the growth of hair on the face, 
shown by a decrease or deficiency of the first, and an in- 
crease of the second, still in the majority of cases no such 
relation is discoverable, and it must be viewed as a de- 
formity, or a freak of Nature, or as a matter of inheri- 
tance. 

Treatment. For general hypertrichosis we can prac- 
tically do nothing. This, not because we cannot destroy 
hair so that it will not grow again, but because of the 
great amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for re- 
lief is that occurring upon the face of women. In 1875 
Dr. Michel, of St. Louis, devised the method of removing 
the hairs in trichiasis by means of electrolysis, which was 
taken up by Dr. Hardaway, of the same city, for the re- 
moval of superfluous hair. The question is often asked : 
" Is the removal, by this method, permanent?" This 
question may be answered, " It is, without a shadow of 
a doubt." The object being to destroy the papilla, and 
that being very small and often placed at an unexpected 
angle to the surface of the skin, it is not possible always 
to accomplish this at the first attempt ; but with patience 
and the necessary skill it will finally be permanently de- 
stroyed. At times, after the dark, coarse hairs have been 
removed, there will be found a number of finer and lighter 
hairs. This appearance is due partly to the uncovering 
of these hairs, and partly, it may be, to lanugo hail's be- 
coming stronger under the stimulation of the operation. 
In most cases, with proper care and the use of a fine 
needle, the amount of scarring will be very slight, amount- 
ing to nothing more than fine punctate cicatricial spots. 
In some peculiarly irritable skins it is very difficult to 
prevent the formation of plainly visible scars. The upper 
lip is also prone to scarring. If the proper conditions are 
not observed, the operator must expect to produce a good 
deal of disfigurement. 

The amount of pain experienced by the patient will 



HYPERTRICHOSIS. 313 

vary greatly. Certain parts of the face are far more sen- 
sitive than others. On the whole, the pain does not 
amount to much. After a time the skin seems to become 
tolerant of the action of the current and the patient no 
longer complains. Hyperpigmentation may be produced 
by the operation. This is a very rare complication, and is 
mentioned only by way of warning. 

The instruments needed for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, a sponge elec- 
trode, a proper needle-holder, a fine needle, a pair of epi- 
lating-forceps, and, if the operator's eyes are not good, a 
lens of low power. Any sponge electrode will answer. 
There are various patterns of needle-holders, any one of 
which may be used. It should be long enough to be held 
with ease, and not too long to be readily manipulated. 
The most essential instrument is the needle. Hardaway 
recommends a needle made of iridium and platinum. He 
claims that it will follow the direction of the hair follicle, 
and more surely hit the papilla than will a steel needle. 
I have had most satisfactory results with a jeweler's in- 
strument called a " steel broach." These come in many 
grades ; those known as Nos. 5 and 7 are serviceable ones. 
A lens is generally not needed. Dr. Piffard has invented 
a needle-holder with lens-attachment, which he has found 
useful. If one's eyesight is not good, he had best wear 
spectacles furnished with large lenses. A galvanometer is 
not essential, but very desirable. 

A good light is necessary for the operation, and a cloudy 
day is a bad one for working. An operating-, reclining-, or 
dentist's chair is a comfort, and the patient should be so 
placed that the part to be operated on is on a level with the 
operator's eye. The operation is done in the following man- 
ner : The patient, being in position, is to be given the sponge 
electrode attached to the positive pole of the battery, and 
told to hold it in one hand. The hair to be extracted is then 
seized with the forceps, and put slightly on the stretch in 
the direction in which it naturally grows. The needle, at- 
tached to the negative pole, is then inserted parallel with 
the hair and into the follicle. One soon learns to know 
whether the follicle is entered or not by the sense of touch. 



314 DISEASES OF THE SKIN. 

When the follicle is entered the needle glides along 
smoothly; when it is not entered a sense of resistance is 
communicated to the fingers as the skin is punctured. 
The depth to which the needle is to be thrust will vary 
with the case. Roughly speaking, it is from one-sixteenth 
to three-sixteenths of an inch. The needle being inserted, 
the patient is told to place the palm of the disengaged 
hand over the sponge electrode. In a few moments there 
will be frothing about the needle, and in from half a 
minute to a minute or more the hair will come away upon 
the very stif/Jifest traction. The hand is to be removed from 
the sponge before the needle is withdrawn from the follicle. 
The hair must not be pulled on with any force, for the 
ease with which it leaves the follicle is evidence of the 
completeness of the operation. The hairs must not be 
extracted in close proximity, because the inflammatory 
action thus set up will lead to more or less deep ulceration 
and subsequent prominent scars. It is best to extract 
only the coarser hair, and to leave the lanugo hairs alone. 
The strength of the current to be used will depend upon 
the quality of the patient's skin and the recentness of the 
filling of the battery. Six cells are the fewest I have used, 
and fifteen the greatest number — more exactly, a current- 
strength of one to two milliamperes. 

Immediately after operating the part worked on should 
be washed with peroxide of hydrogen or an antiseptic 
solution. The patient should be directed to bathe the lace 
in hot water and to anoint it with cold cream several times 
during the day following the operation. 

T. Bloebaum ' advocates the use of galvano-caustic 
needles as superior to electrolysis for the destruction of 
hair. A special needle is used by him, and he destroys 
one hundred hairs in fifteen minutes. He claims for his 
method not only greater celerity, but also less scarring and 
pain. The micro-brenner of Unna has its advocates. Of 
late, the .r-rays have been used to destroy hair, and appar- 
ently successfully. The operation has to be often repeated, 
sometimes as many as thirty to forty times. There is 
always danger of dreadful scarring from their use, but 
1 Deutsche med. Zeit., 1897, xviii., 609. 



ICHTHYOSIS. 315 

improvement in technique is constantly lessening this 
danger. 

Hypohydrosis. See Anidrosis. 

Hystricismus. See Ichthyosis. 

Ichthyosis. Synonyms: Xeroderma; Xeroderma ichthy- 
oides ; Ichthyosis vera, seu congenita ; Sauriasis ; (Fr.) 
Ichthyose; (Ger.) Fischschuppenausschlag ; Fish-skin dis- 
ease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, 
and scaling of the skin, and sometimes by the development 
of warty-looking growths. 

Symptoms. Though the disease is congenital, it usually 
does not show itself until after the second month, and 
sometimes not until the second year. There are three varie- 
ties of the disease, namely, xeroderma, ichthyosis simplex, 
and ichthyosis congenita. 

Xeroderma is the ■ mildest grade of the disease. The 
skin is dry, harsh, slightly scaly, grayish or dirty-looking, 
and its natural lines are more pronounced than usual. 
Upon the extensor surfaces of the limbs it is particularly 
marked, and here too it is accompanied by keratosis pilaris. 
It is most annoying to young women who want to wear 
short-sleeved dresses. It is doubtless far more common 
than statistics show, as it very often is slight in amount, 

Ichthyosis simplex. This is a more severe grade of the 
disease in which the skin is dry, harsh, and scaly, and also 
divided off into small diamond-shaped or polygonal figures 
(Fig. 39). While the whole cutaneous surface may be 
involved, the disease is usually most pronounced upon the 
extensor surfaces of the legs and arms. The face, scalp, 
palms, and soles are often spared. The skin about the 
extensor surfaces of the elbows and knees is generally 
thrown into well-marked folds, while the flexor surfaces of 
the same joints are unaffected, the skin in these situations 
being soft and natural. While upon the extremities the 
disease is well developed, upon the trunk it may assume 
more of the xerodermatous form. When the face and 
scalp are aifected they are simply very scaly, while on the 



316 



DISEASES OF THE SKIN. 



palms and soles we have accentuation of the normal lines 
In a typical case the skin, especially of the extremities 
will be grayish, greenish, or blackish green in color, dry 
and the little polygonal plates will be attached at then- 
centers and turned up slightly at their edges, so that they 
appear depressed in the centers. The amount of loose 

Fig. 39. 




Ichthyosis. 

scaling is sometimes abundant, but usually moderate in 
amount. The hair, if the scalp is involved, is dry. The 
nails are often pitted. Ectropion may result in those rare 
cases in which the disease affects the face severely. Itch- 
ing is often complained of, and eczema may complicate 
matters. There are a marked absence of' perspiration 
and lessened sebaceous secretion ; and the patients are sen- 



ICHTHYOSIS. 317 

sitive to cold. The disease is usually worse in cold 
weather. 

Ichthyosis hystrix used to be described as one form of 
ichthyosis. It is now regarded as a separate malady, and 
has received many names, such as nerve nsevus, nsevus 
verrucosus, neuropathic papilloma, papilloma neuroticum, 
and papilloma lineare. The latter is the preferable title, 
which see. 

Ichthyosis congenita is the most rare form of the disease. 
It is also called Keratoma follicularis, Keratosis diffusa, 
seu epidermica, seu intra-uterina, and the " Harlequin 
foetus." It is considered by some to be a general sebor- 
rhoea. It is present at birth, the skin being covered with 
fatty epidermic plates cracked in all directions and 
arranged transversely to the axis of the body. The fis- 
sures may extend into the corium. The eyes are held 
partly open, or there may be ectropion ; the lips cannot 
be moved ; and the feet are contracted and deformed. 
The color is yellowish white or grayish. The scrotum and 
penis may not be involved. These infants are either born 
dead or survive birth but a short time, though S. Sherwell 
has reported one case that was living at five months of age. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks 
red, glazed, and dry, and soon assumes the characteristics 
of ichthyosis simplex. 

With the exception of ichthyosis congenita, the disease 
does not show itself until some months after birth, but by 
the second year it has made its appearance. As a rule, it 
increases in severity as the patient grows older, until adult 
age, when it usually remains stationary or perhaps im- 
proves a little. It is a chronic disease and shows no 
tendency to get well. It does not seem to affect the 
patient's health, and it should be regarded rather as a 
deformity than a disease. Occasionally mental weakness 
and other congenital defects have been noticed. 

Etiology. We know of no cause for the disease be- 
yond heredity, which may be direct, skip a generation, or 
be through a lateral branch. Many cases occur without 
manifest heredity. It attacks both sexes about equally. 



318 DISEASES OF THE SKIN. 

It shows a tendency to occur only in one sex in certain 
families, while in other families both sexes are equally 
affected. It is a congenital defect in the development of 
the skin with a disturbance of the functions of the per- 
spiratory and sebaceous glands. 

Diagnosis. The disease is so unique that if its char- 
acteristics are remembered there can be no difficulty in di- 
agnosis. There is no other disease commencing in infancy 
that at all corresponds to ichthyosis simplex. Xeroderma 
may resemble a mild grade of squamous eczema, but has 
not its history. Sometimes we meet with a dry skin that 
is not ichthyosis, but is only a passing state and has not 
existed from infancy. Ichthyosis congenita differs from 
seborrluea is not being removable by soaking in oil ; and 
by proving fatal. 

Treatment. The treatment is largely palliative. The 
free use of Russian baths or of prolonged warm baths, 
simple or with soda, and washing with soap, followed by 
inunctions of vaseline, glycerin, lanolin, or oil, such as 
cocoa-butter, will keep the skin supple. Kaposi recom- 
mends a five per cent, naphtol ointment, or a two per cent, 
solution in spiritns sapo. viridis, or cod-liver oil, in con- 
junction with naphtol soap. Andeer 1 recommends a three 
to twenty per cent, ointment of resorcin well rubbed in, 
and covered with a bandage, and claims a cure in eight 
days. Sulphur ointment also has been recommended. The 
daily application of half an ounce to an ounce of glycerin 
in a pint of rose-water or of lime-water is one of the simplest 
and best methods of treatment. Whatever is used must 
be persisted in. 

Besnier recommends, as adjuvants to the local treat- 
ment, regular gymnastic exercise and the internal admin- 
istration of cod-liver oil. Thyroid extract has been used 
with benefit in some cases. It should never be used unless 
the patient can be watched by the physician, as it is a 
dangerous remedy. The administration of jaborandi by 
the mouth or pilocarpine hypodermically will soften the 
skin, but in a deformity of the skin that cannot be re- 
moved its use is inadvisable. 

1 Monatshefte f. prakt. Dermat., 1884, iii., 365. 



IMPETIGO SIMPLEX. 319 

Peognosis. The prognosis is good as to life, bad as to 
cure. Thus far it has proved incurable. All one can hope 
to accomplish is to render the patient comfortable and fit 
to mingle with his kind by repeated courses of treatment. 
Ichthyosis congenita is fatal in a few days, if the child is 
not born dead, as is usually the case. 

Ichthyosis Follicularis. See Keratosis follicularis. 

Ichthyosis Sebacea. See Seborrhoea sicca. 

Idrosis. See Hyperidrosis. 

Ignis Sacer. See Zoster. 

Impetigo is a name that was applied at one time to all 
pustular eruptions. At the present time there are four 
varieties described, namely, impetigo or impetigo simplex ; 
impetigo of Bockhardt ; impetigo contagiosa ; and impetigo 
herpetiformis. The right of the first-named variety to be 
recognized as a distinct aifection is denied by systematic 
writers of all nations but our own. Our own writers 
largely follow Duhring in their description of the disease, 
and as soon as they vary from his description, it seems to 
me that, instead of simple impetigo, they describe the con- 
tagious form. I have never recognized a case, and shall 
here follow Duhring. 

Impetigo Simplex. The appearance of the disease may 
or may not be preceded by loss of appetite, constipation, 
or malaise. The eruption consists of one to a dozen 
or more pustules that are pustules from the beginning. 
They are split-pea to finger-nail in size, rounded, and 
raised above the surface of the skin. They have thick 
walls, a more or less marked areola, little surrounding in- 
filtration, and no central depression. Their color is yel- 
lowish or whitish. They manifest no disposition to rupt- 
ure, are discrete and disseminated, and do not incline to 
coalesce. While they may occur anywhere, they are seated 
by preference on the' face, hands, feet, and lower extremi- 
ties. Itching and burning are absent, as a rule. The 
course of the disease is acute, its duration being several 
weeks. The pustules gradually undergo absorption and 



320 DISEASES OF THE SKIN. 

dry into a crust, or they may be ruptured by external in- 
jury. The crust when it falls leaves a reddish base with- 
out pigmentation or scar. The disease is not contagious, 
and occurs mostly in children. 

Such is the disease as described by Duhring. It will 
be seen by reading the next section that it bears a strong 
resemblance to impetigo contagiosa. He differentiates it 
from impetigo contagiosa on account of its being pustular 
and not vesico-pustular from the start, its deeper seat, and 
its being more raised and not umbilicated. 

Impetigo of Bockhardt. The best description of this 
form of impetigo is by Sabouraud. 1 He describes it as 
occurring primarily on hairy regions, usually the scalp, as 
an eruption of pustules pierced by hairs. They are con- 
fluent or disseminated. They are yellowish green, rounded, 
umbilicated or acuminated, and vary from millet to pea 
size. There is an areola about the young pustules which 
diminishes with their age. They are not readily broken. 
They reach full development in three to five days, the crust 
falling in a week. A folliculitis is often left, or a furuncle 
or abscess follows. There is sometimes a dermatitis of the 
scalp of severe grade, and the glands of the neck are often 
swollen. The disease may spread from the scalp to the 
face, neck, back, thighs, and buttocks. It is due to infec- 
tion with the staphylococcus aureus. 

Impetigo Contagiosa. Synonyms : Porrigo contagiosa ; 
Impetigo parasitica ; Pemphigus acutus contagiosus adul- 
torum. 

An acute, inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesico-pustules and bullae. 

Symptoms. By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to 
be marked by slight febrile disturbances. These are very 
slight, and I have not satisfied myself as to their occur- 
renoe in the many cases that I have seen, except inciden- 
tally as part of some digestive disorder that maybe present. 
The eruption consists of vesico-pustules that come out in 

1 Ann. de derm, et de syph., 1900, i., G2 and 427. 



IMPETIGO CONTAGIOSA. 321 

crops. They are of various ' sizes, but average that of a 
split pea. They are at first surrounded in well-marked 
cases with a red halo, which soon fades. They tend to 

Fig. 40. 



Impetigo contagiosa. 1 

increase slowly in size, and sometimes assume an annular 
shape. They are not fully distended, but flaccid, and 
not infrequently upon the hands they bear a strong re- 
semblance to a burn of the second degree. If the covers 
of the vesicles or small bullae are not disturbed, their con- 
tents in a few days will dry up, and the vesico-pustule 
will change into a straw-yellow granular crust, which is 
placed superficially upon the skin with its edge somewhat 
detached, and, it may be, turned up — in fact, it looks 

1 G. H. Fox : The Skin Diseases of Children. New York, 1897. 
21 



322 DISEASES OF THE SKIN. 

" stuck on." When the crust is removed or falls of itself, 
there is exposed an erythematous spot, which in a short 
time will disappear and leave no trace of its existence. If 
the vesicles are torn by scratching, or if by any other 
means their covers are removed, we shall find very super- 
ficial losses of substance — a moist surface covered with a 
slight purulent secretion or crusted lesions. Even this 
disappears and leaves no trace, passing through the ery- 
thematous stage in its course to recovery. Such are the 
appearances presented in the majority of cases. In adults 
the lesions sometimes assume a circinate form, but the ordi- 
nary impetigo lesions are also present. 

Besides this usual and typical form we meet with another 
and rarer variety, in which, instead of vesico-pustules, 
there are larger bulla?. These may be several inches in 
their long diameter, are of irregular oval shape, not fully 
distended with fluid, and sometimes show a slight depres- 
sion in their centers. Their contents are at first serous, 
but soon become sero-purulent. They seem to be longer 
preserved than the vesicles, but otherwise run the same 
course. At first they have a slight zone of redness about 
them, but this soon disappears. They either are formed 
by two or more vesico-pustules running together, or spring 
up of themselves. They may attain their full size at once, 
or increase slowly. Rarely do they exist alone ; generally 
the typical vesico-pustules will be found in their neighbor- 
hood or elsewhere on the body. It is the bullous form that 
is liable to be mistaken for pemphigus. 

Impetigo contagiosa is located principally upon the face, 
most often on the chin, and on the hands ; it may also 
occur upon the scalp, legs, and trunk, especially in infants. 
According to my experience, the bullous form is most often 
seen upon the trunk. The lesions of both varieties are 
discrete ; exceptionally two or more may run together. 
They are superficial, and rarely very numerous. The 
bullous lesions are generally widely separated from one 
another. The disease docs not run any definite course, 
and may last weeks or months ; a slight amount of itch- 
ing is sometimes present. 

Etiology. It is, as its name indicates, very conta- 



IMPETIGO CONTAGIOSA. 323 

gious, and often occurs in epidemics. When one case is 
met with in dispensary service, several more may be 
expected in children of the same family or neighborhood. 
It is readily inoculable both on the subject of the disease 
and on others. Not infrequently we see a mother or other 
attendant of a child with the characteristic lesions of 
impetigo contagiosa upon the arms, derived from carrying 
the child suffering with the same disorder. The conta- 
gious element is a micro-organism. We know that all pus 
is under certain circumstances inoculable, and hence it has 
been maintained that there is no such disease, properly 
speaking, as contagious impetigo. But when we succeed 
in inoculating from an ordinary pustule, we produce an 
ordinary pustule, not the characteristic vesico-pustule of 
impetigo contagiosa. It has been stated by some authori- 
ties that the disease is due to an inflammation set up 
by lice on the head of the particular case or can be 
traced back to some other case of pediculosis. In some 
cases phtheiriasis capitis may be present, because both dis- 
eases occur with special frequence in children of the poor. 
In my own experience, in most cases no such relationship 
can be traced. Cases of contagious impetigo sometimes 
follow vaccination, and thus has been suggested the possi- 
ble connection between impetigo and vaccinia. It is more 
frequent in the warm months than in the cold. Children 
furnish the vast majority of the cases. 

Pathology. By most observers the disease is thought 
to be due to staphylococcus aureus. Kauffmann l thinks 
he has found a staphylococcus that differs from the ordi- 
nary staphylococcus pyogenes in its cultures, in its less 
resistance to destructive agencies, in its inoculations pro- 
ducing vesicles and not pustules, and in being less virulent. 
Sabouraud 2 and others believe it to be due to streptococcic 
infection ; while still others have found now the one and 
now the other form of cocci in the disease. It is evident 
we need still more light on this subject. 

Diagnosis. Impetigo contagiosa is diagnosed by the 
presence of discrete, partially distended vesico-pustules, 

1 Dermat. Zeitschrift, 1899, vi., 792. 

2 Ann. de derm, et de syph., 1900, i., 62. 



324 DISEASES OF THE SKIN. 

which are located upon the exposed parts — head, face, 
and hands — in most cases ; these are sometimes grouped, 
run an acute course, and dry up into straw-yellow 
"stuck-on" crusts. It is sometimes preceded by slight 
constitutional disturbances, and accompanied by a slight 
amount of itching. It must be differentiated from simple 
impetigo, pustular eczema, varicella, scabies, pemphigus, 
and possibly ecthyma. 

The lesions of simple impetigo are pustules from the 
start, while those of impetigo contagiosa are first vesicles 
and then vesico-pustules. The pustules of impetigo are 
prominently raised, and run no definite course. The 
vesico-pustules of impetigo contagiosa are flattened, and 
run a rather definite course. The crusts of impetigo are 
generally greenish, while those of the contagious form are 
yellowish. Impetigo is not so readily inoculable as is 
impetigo contagiosa, and is much more widely dissemi- 
nated, as a rule. Simple impetigo is a deeper process than 
the contagious form. 

Pustular eczema is itchy ; its pustules tend to break 
down quickly, run together, and form large patches, which 
soon become covered with a greenish or blackish crust. 
These phenomena are entirely foreign to impetigo conta- 
giosa. Eczema does not present vesico-pustules nor bullae, 
as a rule. Varicella is an acute contagious disease, with 
constitutional symptoms in most cases. Its vesicles are 
smaller than those of impetigo contagiosa, and they run a 
definite course peculiar to themselves. They are widely 
distributed over the whole surface, usually appear first on 
the trunk, sometimes occur on the fauces, and not infre- 
quently leave pitted scars. Contagious impetigo is in 
most cases limited to the exposed parts, it never occurs 
upon the fauces, and its lesions leave no trace. The crusts 
of varicella are small, while those of contagious impetigo 
are large. 

The diagnosis from scabies offers little difficulty. In 
fact, the location of both diseases upon the back of the 
hands is their strongest point of resemblance. When we 
bear in mind that scabies is very itchy, that it occurs 
usually as a copious eruption upon the hands, wrists, and 



IMPETIGO CONTAGIOSA. 325 

forearms, about the umbilicus, on the nipples of females 
and the genitals of males ; that scratched papules and 
pustular lesions are more characteristic of it than vesicles, 
and that it presents the pathognomonic furrows, we should 
not confound it with impetigo contagiosa, which has none 
of these symptoms. Further, impetigo will, in almost all 
cases, occur upon the face at the same time as upon the 
hands, and that location is very rarely attacked by the itch 
mite. 

The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparent contagious qualities, were instances of this 
bullous form of impetigo. The diagnosis between the two 
diseases can scarcely be made with certainty by the appear- 
ances of the bulla? alone ; we must also take into considera- 
tion the general course of the disease. The differential 
diagnosis may be given as follows : 



Pemphigus. Impetigo Contagiosa. 

(Bullous form). 

1. Occurs chieflv in adults. 1. Occurs chiefly in children. 

2. No source of contagion can be 2. A source of contagion can usually 

found. be found. 

3. No particular sites of preference ; 3. Met with most often upon the 

if anything, it is most frequent on trunk ; sometimes it may occur on 

the extremities. the face, hands, or extremities. 

4. Chronic in its course; marked by 4. Acute in its course, rarely ' 



frequent relapses ; may return more than a few weeks 

from year to year. 
5 Bullae are fullv distended with a 5. Bulla; not fully distended, but flac- 
clear fluid, so that their covers ap- cid, and contain sero-purulent 

pear tense. Thev often spring up fluid. They may have a well- 

out of the sound skin without marked red halo while slowly at- 

areola. taining their full size. Character- 

istic vesico-pustules are generally 
present elsewhere at the same 
time. 

6. Lesions often occur in great num- 6. Lesions few in number, do not in- 

bers, so as to cover the whole volve the whole body, and itch 

body, and at times are prurigi nous. but little, if at all. 

7. Disease obstinate to treatment, and V. Disease yields readily to treatment ; 

prognosis usually grave. prognosis uniformly good. 

Ecthyma is probably only a form of impetigo contagiosa 
that occurs in broken-down subjects. It affects by prefer- 
ence the lower extremities, is seen most often in adults, 



326 DISEASES OF THE SKIN. 

and its lesions are deep pustules which are highly inflam- 
matory and painful. 

Treatment. The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm water 
and soap to remove the crusts, and covered with a five per 
cent, carbolized vaseline, or with oxide of zinc ointment with 
carbolic acid in the same strength, or with the ointment of 
the ammoniate of mercury in full strength or diluted one- 
half. If there is a good deal of crusting, the crusts may 
readily be removed by soaking them with oil or warm 
water, after which the applications mentioned may be made. 
Salicylic acid may be used in ointment in three to five per 
cent, strength. When there is an eczema complicating 
matters Lassar's paste answers all indications. In the 
bullous form it is well to prick the bulla? at their most 
dependent part, and let the fluid escape, after which the 
lesions may be treated as just indicated. 

Prognosis. The prognosis of impetigo contagiosa is 
always good; so readily is it cured that the patients sel- 
dom present themselves a third time for advice. 

Impetigo Granulata. See Pediculosis. 

Impetigo Herpetiformis. This disease was first de- 
scribed by Hebra 1 in 1872. 

In this country it is exceedingly rare, only a few cases 
having been reported. It is from Kaposi 2 that the account 
here given is taken. 

The disease begins with an eruption of pustules in the 
genito-cniral region, about the umbilicus, on the breasts, 
and in the axillae; later upon various other locations. 
The pustules are crowded together, grouped, pinhead size, 
with at first opaque and later greenish-yellow contents. 
They dry into a dirty-brown crust, while immediately 
around them new pustules appear in double or threefold 
circles, by the drying of which the crust is enlarged. The 
disease spreads by the growth of the individual groups and 
by the coalescence of neighboring ones. Underneath the 
crusts the skin appears red and covered Avith new epi- 

1 Wien. med. Wochenschr., 1872, No. 48. 

2 Pathologie und Therapie der Hantkrankheiten. 



KELOID. 327 

dermis ; or deprived of epidermis, moist, infiltrated, and 
smooth ; or papillary, but never ulcerated. Within three 
or four months nearly the whole cutaneous surface is in- 
volved, swollen, hot, coverec) with crusts, showing torn and 
excoriated places, with here and there circles of pustules. 
The mucous membrane of the tongue may show circum- 
scribed gray patches. There is a continuous remittent 
fever, and each outbreak of pustules is marked by chills, 
high fever, and dry tongue. Nearly all cases prove fatal. 
The disease has affected almost exclusively pregnant 
women, few men having been reported with the malady. 
Delivery has not stopped the course of the disease. It is 
probably of septic origin. 

Diagnosis. The disease is stated by Kaposi to differ 
from dermatitis herpetiformis in being only pustular ; in its 
peculiar location and manner of spreading; in the absence 
of itching ; in the severe constitutional symptoms ; and in 
its lethal ending. 

Teeatment. ~No treatment has proved successful. 
We can only do our best to nourish the patient ; and by 
means of baths, dusting powders, or alkaline lotions render 
her as comfortable as possible. 

Induratio Telae Cellulosse Neonatorum. See Sclerema 
neonatorum. 

Inflammatory Fungoid Neoplasm. See Mycosis fun- 
goid es. 

Intertrigo. See Erythema intertrigo. 

Iodic Acne. See Dermatitis medicamentosa. 

Itch. See Scabies. 

Juckblattern. See Prurigo. 

Kahlheit. See Alopecia. 

Kelis. See Keloid. 

Keloid. Synonyms : Kelis ; (Fr.) Cancer tub6reux, 
Che'loide ; (Ger.) Knollenkrebs. 

A connective-tissue new growth in the skin, occurring 
most commonly upon the chest ; characterized by hard- 



328 DISEASES OF THE SKIN. 

ness, by a pinkish color, and by sending off prolongations 
in all directions, f Fig. 41.) 

SYMP^pMS. It is usual to divide keloids into two 
varieties-, one of which is called the true or spontaneous 
keloid, and the other the false or secondary keloid the re- 
sult^' injuries. Of late the opinion is gaining ground 
that no .such distinction can he made, and that even the 
true keloid results from some slight injury. As most 

Fig. 41. 




commonly met with, it consists in a single, firm, hard, 
pinkish, freely movable, oval or elongated, elevated tumor 
upon the upper half of the sternum, from which claw-like 
processes are given off in all directions. While there may 
be hut one tumor, the lesions may be multiple, there being 
either one large and several small ones upon the chest, or 
1 From <i. II. Fox's Photographs of Skin Diseases. 



KELOID. 329 

many scattered over the body. They begin as small 
pinkish elevations and gradually enlarge until they attain 
a certain size, when they may remain stationary or else 
slowly grow. They assume all sorts of shapes and sizes. 
Sometimes they have an even surface, sometimes they are 
nodular. They may be quite small, or they may be so 
large as to run nearly half-way across the chest. Then 
the appearance is as if the skin were drawn up into 
the tumor. The epidermis is smooth over them, and the 
pink color is due to dilated blood vessels. Sometimes the 
color is white. Though they are rarely met with on the 
face in the white races, they are very common upon the 
face of the negro. They are often attended by a good 
deal of pain, or pruritus, or pricking sensations. 

Beside this form of keloid, that may or may not be 
spontaneous, we have the evident scar keloids that occur 
over the site of an injury to the skin. These have fol- 
lowed syphilides that have destroyed the skin, variola 
pustules, psoriasis, a blister, or acne. 1 They may be lim- 
ited to the site of the previous lesion or spread beyond 
it. This form of keloid is very often seen on the face of 
the male negro who shaves, the cheeks and chin being 
studded over with small, hard, white elevations. The 
hypertrophied scar resembles keloid, but never spreads 
beyond the limits of the injury, has no claw-like processes, 
is not so pinkish nor so permanent. 

Etiology. We know scarcely anything as to the 
cause of keloid, and can only beg the question by saying 
that it is a predisposition on the part of the skin. It is 
probable that some minute injury precedes the tumor. 
The negro race is peculiarly prone to the disease. Sex is 
without influence, and it may occur at any age, though 
rare before puberty and in old age. Histologically the 
structure of the keloid is similar to that of the cicatrix — 
that is, it is a dense fibrous connective-tissue growth which 
has its seat in the true skin. 

Treatment. As a rule, it is safest to leave the growths 
alone. Cutting them out is often disappointing in its 
results, as they are apt to return. Multiple scarifications 
1 Purdon : Journ. Cutan. and Ven. Dis., 1882-3, i., 203. 



330 DISEASES OF THE SKIN. 

followed by the application of acetic acid have been suc- 
cessful. Leloir and Vidal l recommend following mul- 
tiple scarifications with a boric-acid dressing. The next 
day mercurial plaster is to be applied, and changed every 
morning and evening. Perseverance in this method, they 
say, may result in a cure. Compression by means of an 
elastic bandage or by mercurial plaster sometimes reduces 
the prominence of the tumors. Hardaway has succeeded 
in removing one keloid and two hypertrophied scars by 
means of electrolysis, and Brocq has commended the 
method. A stout needle must be used and multiple punct- 
ures made in all directions, and in the tissues for a space 
beyond the tumor. Galvanism is said to reduce hyper- 
trophied scars. Balzer and Mousseaux 2 recommend the 
use of a twenty per cent, solution of creosote in oil. A 
cubic centimeter of the solution is to be injected into many 
points until the tumor pales. This is followed by in- 
flammation, swelling, and sloughing off of a portion of the 
keloid, and rather deep ulceration. After a few days the 
ulcerations are healed and the injections are repeated. 
Andeer 3 recommends resorcin and a bandage. S. Tousey 4 
advocates the use of thiosinamin, and reports some favor- 
able cases. It may be used either hypodermic-ally once a 
day or every other day, twelve to fifteen minims of a ten 
per cent, solution in equal parts of pure glycerin and ster- 
ilized water; or by the mouth, three grains being given 
during the day. I have tried this treatment in a number 
of eases without benefit. Unna recommends thiosinamin 
plasters. Hypodermic injections of morphine, or the ap- 
plication of belladonna ointment, may be necessary to re- 
lieve pain. 

Prognosis. It is possible for hypertrophied scars to 
undergo spontaneous involution. This is especially the 
case in the scar keloid following syphilis. Usually this 
cannot be expected in true keloids. 

Keloid of Addison. See Morphoea. 

1 Ann. <le derm, ct de syph., 1890, i., 193. 

2 Ibid., 1898, ix., 1147.* 

3 Centraibl. f. med. Wissensrhnft, 1888, xxvi., 785. 

4 New York Med. Journ., 1S97, lxvi., (121. 



KERATOSIS FOLLICULARIS. 331 

Keloid of Alibert. See Keloid. 

Keratoangioma. See Angiokeratoma. 

Keratodermia Excentrica. See Porokeratosis. 

Keratolysis Exfoliativa is the name applied by A. Sang- 
ster x to a case of congenital exfoliation of the skin which 
resembled ichthyosis, excepting that its scaling was more 
papery, like that seen in dermatitis exfoliativa. 

Keratosis Circumscripta. See Ichthyosis. 

Keratosis Diffusa seu Epidermica. See Ichthyosis con- 
genita. 

Keratosis Follicularis. This is a rare affection of the 
skin to which especial attention has of late been given. It 
is probably the same as was described by Guibout by the 
name of acne sebaeie cornee, and by Lesser as ichthyosis 
follicularis. The French have named it psorospermose fol- 
liculaire vegttante, but as this title was given it by Darier 
and Thibault in 1 889, under the idea that it was due to 
psoro'sperms, which have been shown to be only degenerate 
epithelium, and as Morrow 2 had already reported a case 
in 1886, with the title of keratosis follicularis, and White 3 
another in 1889, under the same title, it seems to me best 
to retain their title. 

Symptoms. The disease affects nearly the whole cuta- 
neous surface, though in both Morrow's and "White's cases 
the palms and soles were free. The eruption begins as 
pinhead-sized papules, which are firm and of the color of 
the skin. As they increase in size they become hypersemic; 
still growing, they become hemispherical or flattened, with 
smooth or polished, dense adherent coverings of nail-like 
consistence, and varying in color from dull red to purplish, 
dusky red, brown, and brownish black. Some of them 
are excoriated by scratching and bear hemorrhagic crusts. 
These lesions are discrete, and the skin about them normal. 
They are located in the hair follicles. In places the lesions 

1 Brit. Journ. Dermat., 1895, vii., 37. 

2 Jourti. Cutan. and Ven. Dis., 1886, iv., 257. 

3 Journ. Cutan. and Gen.-Urin. Dis., 1889, vii., 201. 



332 DISEASES OF THE SKIN. 

run together and form elevated areas with uneven surfaces 
and covered by thick yellowish or brownish, flattened 
horny concretions; or there may be brownish or blackish 
plates. The patches feel rough and somewhat greasy. 
Here and there will be found papillomatous excrescences ; 
or enormously dilated follicular openings filled with comedo- 
like, firm, slightly projecting concretions forming hemi- 
spherical elevations, which when expressed are found to be 
hard and perfectly dry, leaving the follicle mouth patulous. 
The nails are coarse, slightly thickened, and ragged at 
their free edges. Boeck 1 says that they are often the seat 
of a marked hyperkeratosis without a trace of the disease 
itself anywhere in their neighborhood. The hard palate 
in White's case showed some follicular elevations. Pruri- 
tus is marked in some cases. A fetid odor is given off 
from the patient. 

Upon the scalp the disease appears for a long time as a 
seborrhoea sicca, but later the same elevations about the 
hairs can be made out as are seen upon the general integu- 
ment. Upon the back of the hands and fingers the erup- 
tion presents the appearance of simple papillary growths, 
little pale-white, slightly raised, confluent and adherent 
masses. Upon the palms and soles, instead of elevations, 
we find punctate depressions, and perhaps a hyperkeratosis. 
In the axillse, on account of maceration by sweat, the 
masses are not so hard and horny, and the scales can be 
rubbed off, when a moist, red, warty surface is exposed. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. 
It seems to have no damaging effect on the health. It 
affects specially the scalp, axilla?, inguinal region, abdomen 
below the umbilicus, back of the hands and feet, and the 
wrists. 

Etiology. We know nothing positive about the etiol- 
ogy of this rare affection. White met with it in a father 
and daughter, and that would suggest the idea of heredity. 
The disease may begin at any age, cases having been 
reported as commencing in the first weeks of life, in the 
sixth, sixteenth, twenty-second, twenty-seventh, and thirty- 
1 Arch. f. Denn.it. u. Syph., 1891, xxiii., 857. 



KERATOSIS PALMARIS ET PLANTARIS. 333 

sixth year, though most cases occur before the twenty-fifth 
year. Males are more often affected than females. 

Pathology. J. T. Bowen, who made a careful ex- 
amination of White's first case, says that " the disease is 
a keratosis of the epithelial lining of the mouths of the 
follicles, which, by extension downward, gradually pro- 
duces pouch-like depressions in the corium. The capacity 
for corneous metamorphosis is so great that the central 
portion becomes a firm horn, which by production of horny 
matter from below is gradually pushed out above the sur- 
face of the skin. There was no proof that the sebaceous 
glands were affected by the horny change." The keratosis 
may occur outside of the mouths of the follicles. Robin- 
son found in Morrow's case that the changes occurred 
principally in the sebaceous glands. 

Diagnosis. The disease differs from pityriasis rubra 
jjilaris in lacking the constant and early involvement of 
the palms and soles ; in the isolated papules pierced by 
hairs on the dorsum of the fingers ; in the extensive, dif- 
fused, scaly dermatitis of the face, neck, and other parts ; 
and in having horny plugs. 

Tkeatmejstt. The proper treatment is yet undeter- 
mined. It might be well to try the methods found useful 
in ichthyosis. It is always a very obstinate disease, relaps- 
ing after the skin manifestations have been removed. 

Keratosis Palmaris et Plantaris. This is a form of con- 
genital or acquired callositas. It has also been called 
keratoma palmare et plantare hereditarium, ichthyosis 
palmaris et plantaris, tylosis palmse et plantse. It is char- 
acterized by the appearance upon the palms and soles of 
masses of thickened skin of leathery consistence and yellow 
or brown color. They come without apparent cause, and 
usually show a symmetrical arrangement. The palms 
or the soles alone may be affected, but it is always both 
palms or both soles that are affected. There is sometimes 
a zone of redness about the thickened plates. Sometimes 
the whole palm or sole is covered, sometimes the horny 
masses occur in islands. The plates may be shed period- 
ically, only to re-form. The surface of the plates may be 



334 DISEASES OF THE SKIN. 

smooth or uneven. Hyperidrosis is frequently marked. 
The nails at times show hypertrophic (manges. Pain may 
be complained of when the hands or feet are used. If the 
feet are affected, the pain may be so great as to prevent 
walking. 

One form of the disease is due to the prolonged inges- 
tion of arsenic. It occurs in a number of isolated points 
over the palms and soles. 

Etiology. The disease is hereditary in many instances, 
and like ichthyosis tends to affect only one sex in the 
family. We do not know its cause, and we class it as a 
tropho-neurosis. It sometimes has been noted to follow 
the prolonged ingestion of arsenic. 

Treatment. The plates may be removed by salicylic 
acid plaster or ointment, ten to twenty per cent, strength. 
The same end is reached by poultices, the wearing of 
rubber sheeting, and the application of various plasters. 
A permanent cure can hardly be exjiected. 

Keratosis Pigmentosa. See Verruca senilis. 

Keratosis Pilaris. Synonyms : Lichen pilaris ; Pity- 
riasis pilaris ; Ichthyosis sen hyperkeratosis follicularis ; 
Cacotrophia folliculorum ; (Fr.) Xerodermie pilaire, Ich- 
thyose anserine des scrofuleux. 

Symptoms. As its name indicates, this is a disorder of 
cornification. It is characterized by a heaping up of the 
corneous cells about the mouths of the hair follicles in 
the form of small conical, whitish or grayish elevations. 
Between them the texture of the skin is normal ; its color 
may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of the 
limbs, especially upon the upper arm and thigh, but may 
occur anywhere. The appearance of the affected part re- 
sembles cutis anserina, being dotted over with pinhead- to 
small-pea-sized papules, each one of which is either pierced 
by a hair or has a black dot at its summit indicating the 
mouth of the hair follicle. The papules are often scaly. 
The hair is either normal, broken off, or only to be found 
by opening the papule, when it will be seen curled up 
inside of it, The skin feels dry and harsh. There may 



KERATOSIS SENILIS. 335 

be slight pruritus. Pityriasis capitis may be present at 
the same time. As the disease is attended by but slight, 
if any, subjective symptoms it is often overlooked. It is 
a chronic affection in most cases. 

Brocq describes a keratosis pilaris of the face beginning 
as minute scaly papules about the hairs, which crowd to- 
gether to form patches and give a rosy or red tint to the 
skin. After a time the disease seems to destroy the fol- 
licle, and we find depressed scars arranged in rows or 
scattered about on the red patch. This bears some re- 
semblance to lupus erythematosus, and is the ulerythema 
ophryogenes of Taenzer. Besnier describes a somewhat 
similar condition as occurring upon the extremities. 

Etiology. The disease is sometimes congenital and 
often forms a part of ichthyosis. It is most common in 
women, and those who do not bathe frequently, or in 
whom there is cutaneous inactivity or a peculiarly coarse 
quality of skin. 

Diagnosis. It differs from cutis anserina in being a 
permanent condition ; from the miliary 'papular syphilide 
in being whitish, grayish, or blackish, and not dark-red or 
raw-ham color, and in being removable by soap and water. 
Lichen scrofulosorum occurs in strumous subjects and in 
well-marked circular or crescentic patches, which is for- 
eign to keratosis. Papular eczema differs in being very 
itchy, and in having red inflammatory lesions. Ichthyosis is 
a general affection of congenital origin, has peculiar mark- 
ings of the skin, and is not limited to the hair follicles. 

Treatment. The vigorous use of green soap and water 
in an alkaline bath, followed by oil or vaseline, will re- 
move the evidences of the disease. Vapor or Russian 
baths may be used for the same purpose. Hyde prefers 
general cool baths containing one-quarter of a pound of 
common salt to each gallon of water, after taking which 
the skin is to be rubbed with a coarse towel or flesh-brush. 
As the affection is allied to ichthyosis, it may be treated 
on the same plan, a new course of bathing being taken 
with each relapse. 

Keratosis Senilis, $ee Verruca senilis. 



336 DISEASES OF THE SKIN. 

Kerion. Synonyms : Trichomykosis capillitii ; Tinea 
kerion; Kerion Celsi. 

Symptoms. This is a more or less chronic inflamma- 
tion of the scalp or beard that most often is a form of 
ringworm, but may be produced quite independently of 
that disease. It is most commonly seen on the scalp. 
The affected part becomes red, oedematous, swollen, and 
boggy, and may assume a purplish color. Its surface is 
glazed, uneven, and studded with a number of yellowish 
suppurating points, or with foramina out of which oozes 
a sticky, viscid, gelatinous, transparent fluid. Sometimes 
suppuration may occur attended with a sero-purulent dis- 
charge. The swelling is round or oval in shape, and 
varies in size ; it may be but one or two inches in diam- 
eter, or as large as a turkey's egg. The pustules form 
about the hair in the early stage ; later the hairs fall and 
the discharge takes place from the openings of the hair 
follicles. If the tumor is opened, a thick, viscid material 
escapes. If the disease occurs with ringworm, the hair 
will be broken off. Permanent baldness may result if the 
inflammation is intense. There are more or less pain and 
tenderness, and at times itching and burning. The pos- 
terior cervical glands may be enlarged. 

Etiology. The disease is comparatively rare. It oc- 
curs chiefly in children of poor constitution. It is most 
commonly due to the trichophyton fungus passing deep 
down into the hair follicles, but may be caused by the ap- 
plication of irritants to the scalp, or follow eczema, favus, 
or sycosis of that part. 

Diagnosis. Kerion must be diagnosed from an abscess, 
a papilloma, a gumma, and a sebaceous cyst. An abscess 
is not preceded by ringworm, has no history of an irritant 
applied to the scalp, and may arise without any antece- 
dent disease of the scalp ; it is more painful ; it is often 
accompanied by a sensation of throbbing, by chilliness, 
fever, and general malaise ; when fully formed there is 
fluctuation, and when opened it gives exit to pus. These 
symptoms are not met with in kerion. A papilloma is 
non-inflammatory, firm to the touch, and is unaccom- 
panied by a discharge, A gumma is usually accompanied 



KRAUROSIS VULVsE. 337 

by other signs of syphilis, and tends to break down and 
ulcerate. A sebaceous cyst is slow in its growth, the skin 
over it is normal, there is no discharge, and when opened 
it gives vent to a cheesy mass. A fatty tumor is a chronic, 
elastic, freely movable swelling, with normal skin over it. 
Treatment. In treating a case epilation should be 
performed in order to save the hair and give exit to the 
discharge. If some irritant application is the cause, that 
should be discontinued, and hot-water dressings, antiseptic 
solutions, or mild emollient applications employed. If 
the cause is ringworm, the remedies proper for that disease 
should at once be used. What they are will be found 
under Trichophytosis capitis. 

Kleienflechte. See Chromophytosis. 

Kohlenbeule. See Carbuncle. 

Kopskurv. See Favus. 

Knollenkrebs. See Keloid. 

Kratze. See Scabies. 

Kraurosis Vulvae is a name proposed by Breisky 1 for a 
form of atrophy of the skin of the external genitals of 
women, which may occur at any age. The disease has its 
seat in the vestibule, the labia minora with the frenulum 
and prseputium clitoridis, the inner surfaces of the labia 
majora up to the posterior commissure, and the contiguous 
skin of the perineum. It gives rise to the appearance of 
a defect in the development of the normal folds of the 
vulva. At times the labia minora and the prseputium 
clitoridis are apparently wanting. The affected skin is 
white and dry, the epidermis is often thickened, and tel- 
angiectasia vessels are visible. Stenosis of the vulvar en- 
trance may result, and thus obstruction be offered both to 
coitus and parturition. The cause is obscure ; possibly a 
long-continued blennorrhoea, or a congenital defect, or a 
process analogous to leucoplakia buccalis. Treatment is 
of no effect. 2 

1 Zeitschrift f. Heilkunde, 1885. 

2 Janovsky : Monatshefte f. prakt. Dermat., 1888, vii., 951. 
22 



338 DISEASES OF THE SKIN. 

Krebs is the German for cancer. 

Kupferfinne. See Rosacea. 

Kupferrose. See Rosacea. 

Kup friges Gesicht. See Rosacea. 

Kwe-na. A disease occurring in Burmah and said to 
be the same as Yaws. 

Lausesucht. See Pediculosis. 
Leberflecken. See Chloasma. 
Leichdorn. See Clavus. 
Leiomyoma Cutis. See Myoma. 

Lentigo. Synonyms : Eph elides ; (Ger.) Sommerspros- 
sen, Linsenflecke ; Freckles. 

Freckles are properly a species of chloasma. They 
occur as light to dark brown or even black macules, and 
are usually located upon exposed parts, especially the face 
and back of the hands, but they may occur anywhere. 
In size they vary from that of a pinhead to that of a split 
pea. They give rise to no subjective symptoms. They 
usually do not appear before the eighth year of life, but 
congenital cases have been reported. The latter should 
rather be classed among the pigmentary mevi. A division 
is sometimes made between those which are permanent and 
occur upon unexposed places and those which occur in 
summer to disappear in winter. To the former the name 
lentigo is given, and to the latter ephelidcs. The distinction 
is not worth preserving. As old age is approached freckles 
no longer form, and the old ones are apt to disappear. 

Etiology. The cause of freckles is probably an in- 
born peculiarity of the skin. It has been advanced as a 
theory of their production that they are due to the chem- 
ical action of the sun's rays upon the blood. Blondes are 
more prone to them than are brunettes. Many people 
never freckle. Symptomatically they occur as part of 
atrophoderma pigmentosum. 

Pathology. Freckles are but circumscribed deposits 



LEPOTHRIX. 339 

of pigment. Colin 1 has endeavored to show that lenti- 
gines differ from ephelides in being discrete, slightly ele- 
vated, and having their pigment in all the layers of the 
epidermis, as well as in the cutis, and in being associated 
with changes in the blood vessels of the cutis ; while 
ephelides are crowded together, their pigment is only in 
the basal layer of the epidermis, and there are no changes 
in the blood vessels. 

Treatment. The treatment of freckles is the same as 
that of chloasma. The only prevention is to protect the 
skin from the action of the sunlight by wearing veils or 
by the use of some lotion containing a pigment, such as 
calamine lotion. Hardaway recommends the following : 



R Hydrarg. 



amnion.. 



Bisniutbi subnitrat., 



aa 3j ; aa 4 



Ungt. aq. rosse, ad 3J ; ad 30| M. 

He speaks highly also of electrolysis for the removal 
of very black freckles. JBulkley recommends the fol- 
lowing : 

R Hydrarg. bichlor., gr. vj ; 

Acid, acetic, dil., 3y ; 6 

Ac. boric, gr. xl ; 2 

Aquse rosse, ad §iv; ad 100 M. 

This is to be used night and morning, at first gently, but 
afterward to be well rubbed in. 

There is hardly any use in endeavoring to cure freckles 
occurring from the action of the sun, as they depart of 
themselves. 

Lentigo Maligna. See Atrophoderma pigmentosum. 

Leontiasis. See Leprosy. 

Lepothrix. This is a condition of the hairs of the 
axilla? and scrotum which presents itself as diffuse or 
nodular incrustation of the hair, which is composed of a 
parasitic growth. The hairs are not diseased, but simply 
form a ground for the growth of the parasite. It is met 
with in those who sweat freely. Sometimes the masses 
1 Monatsliefte f. prakt. Dermat., 1891, xii., 119. 



340 DISEASES OF THE SKIN. 

are red. They may be removed with soap and water, and 
prevented by the use of a mild antiparasitic lotion. 

Lepra. Synonyms : Elephantiasis Graecorum ; Leonti- 
asis ; Satyriasis ; Lepra Arabum ; (Fr.) La Lepre ; (Ger.) 
Der Aussatz ; (Norweg.) Spedalskhed ; Leprosy. 

A chronic, endemic, constitutional disease due to infec- 
tion by a specific bacillus ; characterized by anaesthesia, 
erythematous patches, tubercles, ulcerations, atrophies, and 
deformities according to the structures most affected ; and 
ending in death. (Fig. 42.) 

Symptoms. It is usual to describe three forms of lep- 
rosy — the tubercular, the anaesthetic, and the mixed. This 
is convenient for clinical purposes, though not absolutely 
correct, as even in the nearly pure tubercular form there 
is more or less anaesthesia. All forms exist in all endemic 
regions, but now one and now another form predominates. 
The tubercular form is the one most common in cold coun- 
tries, the anaesthetic in hot countries. Morrow, 1 however, 
found that in the Sandwich Islands the tubercular form 
constituted one-half of the cases, while the anaesthetic 
form formed but one-third of them. 

Tubercular leprosy. Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 
months before the disease frankly declares itself the patient 
is out of health. He feels indefinitely ill, depressed, and 
listless ; he has dyspepsia and diarrhoea ; he is weak, 
chilly, and suffers from profuse sweating. There may be 
nose-bleed. Then a remittent fever of malarial type ap- 
pears. This fever may occur without the other prodro- 
mata, and may recur with each new outbreak of tubercles. 
After a time an erythematous eruption appears upon the 
face, ears, the forearms, and thighs. It consists of purplish 
or mahogany-red, slightly raised, hyperaesthetic, smooth, 
shiny patches, of one or several inches in diameter, usually 
<if oval form. The eruption may fade entirely away, to 
appear again with a fresh outbreak of fever. After some 
three to six months of the exanthem the tubercles appear, 
either upon the sites of the previous lesions, or quite in- 

' Now York Med. Joum., 1889, 1., 85. 



LEPRA. 



341 



dependency of them. They begin as pinhead-sized pink 
papules that enlarge to split-pea- or even to hen's-egg- 
sized, yellowish-brown tubercles. If a number of these 



Fig. 42. 




Tubercular and anaesthetic leprosy. 1 



run together, large infiltrated patches are formed of irregu- 
lar shape and nodular surface. Then infiltrations may 
also arise by an increased deposit of leprous material in 

1 From a photograph kindly loaned me by Dr. P. A. Morrow, of 
New York. 



342 DISEASES OF THE SKIN. 

the macules, for the macules themselves are formed of 
leprous material, and are not simply erythematous lesions. 
Sometimes the infiltrated patches that arise from the 
macules may assume ring shapes, by clearing up in their 
centers. The tubercles are completely anaesthetic. They 
may come anywhere, but are most commonly seen in the 
eyebrows, lobes of the ears, the face generally, and upon 
the extremities. They are rare on the glans penis, palms, 
and soles. The scalp is said never to be affected. The 
mucous membranes of the mouth, nose, larynx, trachea, 
uterus, and vagina are also involved, as may be the con- 
junctivae. The tubercles may undergo spontaneous invo- 
lution in one place, while fresh outbreaks of them occur in 
other places. Or they may soften and break down and 
form leprous ulcers, which are indolent, sharply defined, 
and glazed over with a mucous discharge of peculiar odor. 
These may attain enormous dimensions, becoming serpigin- 
ous and phagedenic. When these ulcers go deep, as they 
may do on the lower extremities especially, there may take 
place spontaneous amputation of the fingers, toes, or whole 
members. This is one form of mutilating leprosy, which 
is most frequently encountered in the anaesthetic form of 
the disease. Or the tubercles may, on disappearing, leave 
atrophic spots. Their development and involution are 
always slow. The appearance of a well-developed case is 
striking. The face is deformed by the tubercles, and as- 
sumes the "leonine" expression on account of the thick- 
ening of the eyebrows causing them to protrude, so that 
the eyes are sunken and have a stern expression. The 
hair is wanting in the eyebrows. The immense lobes of 
the ears hang down. The lips protrude and are often 
everted. Tubercles stud the face. The forearms are 
enlarged and knobby. The hands are deformed. There 
is very commonly a discharge from the nose, a disagreeable 
odor from the mouth, and the sense of smell is lost. The 
eyesight is often lost; the voice is cracked and croaking. 
The lymphatic glands are often swollen. Happily, both 
in men and women sterility is the rule. There are com- 
monly atrophy of the testicles and loss of sexual power in 
men. The disease is steadily progressive, and death occurs 



LEPRA. 



343 



in eight years on an average, though the disease may last 
for many years. Crocker says forty per cent, die of the 
disease itself, forty per cent, die from renal or lung com- 
plications, and the rest from diarrhoea, ancemia, or general 
marasmus. 

Ancesthetic leprosy announces its onset not by febrile 
symptoms, but by shooting, lancinating pains in the chief 





Macular leprosy. 

nerve-trunks, as the ulnar, median, peroneal, and saphen- 
ous. There are also pain and tenderness in various places, 
and a state of general hyperesthesia. Itching is regarded 
by Morrow as being one of the most common and charac- 
teristic prodromata of this form of leprosy. There may 
also be symptoms of general malaise and digestive disturb- 



344 DISEASES OF THE SKIN. 

ances. A frequent early symptom is a vesicular or bul- 
lous eruption upon the fingers and toes, with at first ser- 
ous, then purulent contents. These may burst and leave 
a white, shining, anaesthetic spot, or an ulceration that 
heals with an anaesthetic cicatrix. Numbness soon follows 
the hyperaesthetic state. The patient cannot grasp things 
firmly, and the consequent unskilfulness of his action may 
be the first thing to attract his attention. This shows 
muscular weakness as well as numbness. 

After some months of these prodromal symptoms an 
eruption of macules similar to those of the tubercular 
variety appears upon the extremities, face, and back. They 
are isolated, of oval shape, hardly raised above the sur- 
face, and of a pale-yellow to reddish-brown color. These 
often enlarge peripherally and clear up or become atrophic 
in the center. Sometimes, instead of being oval, they will 
take the form of wide streaks or of gyrate figures. They 
are often hyperaesthetic when newly formed, but always 
perfectly anaesthetic when they have become atrophic, and 
even before that in cases that have lasted some little time. 
The large nerve-trunks, as that of the ulnar, are at first 
hyperaesthetic, but later are anaesthetic and can be felt like 
a whip-cord, and rolled about under the finger without 
giving rise to pain. Anaesthetic areas will be found in- 
dependently of the macules, and in old cases a rather gen- 
eral anaesthesia develops, so that the patient may burn 
himself without noticing it. The anaesthetic areas are 
subject to change from time to time. Solitary bullae appear 
from time to time, as well as urticaria-like lesions. Marked 
atrophy of the muscles of the hands and feet occurs, and 
paralysis of the extensor muscles of the second and third 
phalangeal joints. Wasted interossei muscles and per- 
manent flexion of the last phalanges of the fingers give as 
characteristic an expression to the hand in this form of 
leprosy as the tubercles do to the facial expression of the 
tubercular form. After some ten years or so, during which 
the greater part of the cutaneous surfaces may have be- 
come studded over with white, wrinkled, hairless, atrophic 
spots, the permanent stage is reached. During these years 
painless amputation of many of the joints may have oc- 



LEPRA. 345 

curred by a process of dry gangrene (Lepra mutilans). 
Erysipelas may occur. The nails and hair are shed. 
Sleeplessness may prove a distressing symptom. Loss of 
sexual power and sterility are manifest late in the disease. 
There is marked anaesthesia of the soft palate, uvula, and 
pharynx. This form lasts much longer than the tubercu- 
lar form, fifteen years being an average duration. Some- 
times a fair degree of health is preserved for a much 
greater length of time. In most all cases more or less 
hebetude of mind is marked, becoming more pronounced 
with the duration of the disease. 

The mixed form is a combination of the symptoms of 
the two former varieties, and perhaps is the one most 
commonly met with in this country. Indeed, it is the rule 
that all tubercular cases present certain symptoms of the 
anaesthetic form, and vice versa, the variety being named 
from the prevailing lesion. 

Etiology. Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by 
the seashore, eating of putrid fish, heredity ; but in the 
light of our present knowledge there is but one cause, and 
that is contagion. The limits of this book forbid full dis- 
cussion of this interesting topic, but an incontrovertible 
argument for this view is found in the spread of the dis- 
ease in the Sandwich Islands, where, within a few years 
after its introduction, it decimated the community. The 
contagiousness of the disease is a strong plea for the segre- 
gation of the -lepers within our own country. 

Leprosy is seen in both sexes, though the male sex is 
more often aifected. It is rare in children, and is never 
seen in infants ; a strong argument against heredity. Its in- 
cubation stage is very long, reaching over a period of years. 
It occurs in all countries and climates, but is endemic in 
certain regions. It seems that a damp, cold climate, or a 
hot, moist climate favors the disease. Sporadic cases have 
been reported, but careful investigation would doubtless 
show that they had been exposed to contagion. Vaccina- 
tion has been a carrier of contagion. 

Pathology. Constantly accumulating evidence points 
to the bacillus leprae as the disease carrier. This has been 



346 DISEASES OF THE SKIN. 

found in the tubercles, the infiltrations, the lymphatic 
glands, nerves, spleen, liver, walls of the blood vessels, 
hair follicles, and sebaceous elands. It was discovered 
by Hansen in 1S74, and since then has been studied by 
many pathologists. "This bacillus occurs as straight or 
very slightly curved rods, 5 q s of an inch in length, which 
may have knob-shaped expansions at their ends or in 
their length, due to the presence of two to five spores." 
(Crocker.) Culture-experiments have for the most part 
failed, and inoculation-experiments have resulted nega- 
tively. 

Diagnosis. In a fully developed case little difficulty 
in diagnosis can arise. Sometimes lepra will need to be 
differentiated from erythema multiforme; syphilis; lupus; 
morphoea ; and vitiligo. The presence of anaesthesia in 
any doubtful case will establish the diagnosis of leprosy. 
Besides this, erythema runs a more acute course; syphilis 
of the tubercular form presents redder tubercles, which 
ulcerate more readily, are grouped, and a history of syphi- 
lis is usually attainable; the lupous tubercles arc small, of 
apple-jelly color, soft, do not produce thickening of the 
eyebrows and nodular lobulation of the ears, and group 
themselves in patches in which cicatricial tissue will be 
found; morphoea has a lardaceous appearance with a viola- 
ceous border; vitiligo patches are more lead-white and 
sharply defined, while the skin is unaltered in texture and 
normal in sensation. 

Treatment. The 1 >est chance for recovery from leprosy 
is removal to a region where the disease is not endemic. 
This, with attention to hygiene, and a general tonic treat- 
ment, will do a great deal toward a cure. Of internal 
remedies, chaulmoogra oil holds the first rank, with an 
initial dose of three minims three times a day, and then 
gradually increased to as high a dose as the patient will 
stand. Nausea, vomiting, and diarrhoea show when this is 
reached. G. H. Fox 1 has cured one patient by giving mix 
vomica or strychnine up to full constitutional effects, and 
then administering chaulmoogra oil continuously. Gurjun 
oil is also highly commended in an emulsion of one part 
1 Post-Graduate, 1885-6, i., 143. 



LEPRA. 347 

of the oil and three parts of lime-water, of which the dose 
is half an ounce morning and night. 

Unna claims to have cured one case with sulpho-ichthy- 
olate of sodium, from six to forty-five grains a day, hut 
others who have tried it have not had the same success. 
Salicylate of soda, thirty grains every four hours till two 
drachms are taken ; salol in full doses ; thymol, forty-five 
to sixty grains a day ; carbolic acid up to fifteen grains a 
day, are advocated by Lutz, Besnier, and others. The 
general health of the patient should receive attention, and 
symptoms treated as they arise. H. R. Crocker 1 has had 
good results in one case by weekly and then semi-weekly 
hypodermic injections of one-fifth of a grain of calomel. 

Externally the chaulmoogra or gurjun oil may be rubbed 
in. The ulcers are to be treated upon the usual surgical 
principles. Unna 2 recommends rubbing into all the lesions 
but those on the hands and face the following : 

R Clirysarobin., "I . -- - 

Ichthyol., ( 3 ls s ; aa o 

Ac. salicyl., gr. xl ; 2 

Ungt. simpl., ad§iv; ad 100 

On the face and hands he substituted pyrogallol for the 
clirysarobin. To counteract the bad effects of the drugs 
he administers thirty drops of dilute hydrochloric acid 
during the day. For women and children he substitutes 
resorcin for the clirysarobin. To old nodes, after protect- 
ing the surrounding skin, he applies during five to seven 
days a plaster mull containing twenty to forty parts of 
salicylic acid and forty parts of creosote. 

The so-called Bhau Daji treatment 3 is said to have pro- 
duced remarkable effects in from six to eight weeks after 
it was begun. It consists in the use of the oil of hydno- 
carpus inebrians, of which from TTLlO to 3ss is taken in 
the morning in boiled milk. The patient is also anointed 
with the oil. Two hours afterward the oil is washed off 
in a warm bath. He is anointed on going to bed. He is 

i Lancet, 1896, ii., 364. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 381. 

3 Brit. Journ. Dermat., 1893, v., 203. 



348 DISEASES OF THE SKIN. 

not allowed to eat pork, beef, or fish, nor to drink alcoholics, 
tea, or coffee. He is fed on milk, fruit, vegetables, butter, 
eggs, mutton, and fowls. Roake 1 advocates excision of 
the tubercles, followed by the application of pure carbolic 
acid. The thermo- and electro-cautery may be used to the 
same end. Segregation is the only preventive measure. 

Prognosis. The prognosis is bad, as the disease 
steadily progresses to a fatal termination unless the patient 
can be removed from the endemic region. If he can be 
removed, there is a chance of staying the disease. In 
some instances the disease, even when the patient does 
not change his residence, pauses in its course for a long 
time ; but eventually it will again become active. 

Lepra Alphos. See Psoriasis. 
Lepra Arabum. See Elephantiasis. 
Lepre Vulgaire. See Psoriasis. 
Leprosy. See Lepra. 
Leucasmus. See Leucoderma. 

Leucoderma. Synonyms : Vitiligo ; Leucasmus ; Leu- 
copathia ; Achroma ; Piebald skin. 

An acquired loss of pigment of the skin characterized 
by the formation of symmetrical white patches with convex 
borders surrounded by an area of hyper-pigmentation. 

Symptoms. This is an acquired anomaly of pigmenta- 
tion, the opposite to chloasma. It is akin to albinismus, 
only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 
scribed round or oval patches so that white areas are formed. 
(Fig. 44.) At the same time there is an accumulation of 
pigment around the areas, so that there is at once a process 
of apigmentation and of hyper-pigmentation. The size of 
the patches varies greatly. They may be no larger than a 
ten-cent piece or of immense size. The disease most com- 
monly begins upon the neck, face, or backs of the hands, 
but may begin anywhere. It is chronic. It may progress 
so as eventually to involve nearly the whole body ; or it 
1 Brit. Med. Journ., 1888, i., 1214. 



LEUCODERMA. 



349 



may become stationary ; or, in rare cases, the skin may 
become pigmented again. It is a symmetrical disease in 



Fig. 44. 




Leucoderm.a. (After Hyde.) 



nearly all cases. The general health is unaffected, and 
there is no change in the sensibility of the patches. In 



350 DISEASES OF THE SKIN. 

some cases the white parts are unusually sensitive to expos- 
ure to the sun. When the scalp or hairy regions are 
affected the hair turns white. The disease is most evident 
in the summer on account of the increased pigmentation 
that normally occurs in the sound skin at this season. 

Etiology. The cause of the disease is obscure. All 
we can now say is that it is probably a disturbance of in- 
nervation. It is uncommon for it to occur before the tenth 
year of life, though it may do so. Adults are most fre- 
quently affected. Both sexes are subject to it. It is more 
common in the warm than in the cold countries, and is 
particularly common in negroes. Exposure to the sun 
and cold seems to be an excitant in some cases. It has fol- 
lowed typhoid fever, scarlatina, and malarial fever. Wood ' 
says that when mulattoes contract syphilis they become 
several shades lighter all over the body. Symptomatically 
it is seen with morphea, Addison's disease, and alopecia 
areata. There is also a syphilitic lencoderma. I have 
had one case in a man of eighteen years, who began to 
smoke tobacco when he was six years of age, and had con- 
tinned to do so. He seemed to be in the best of health. 

Diagnosis. There is little difficulty in diagnosis, as 
there is no other disease in which the only symptom is a 
loss of pigment with surrounding pigmentation. In mor- 
phoea the patch may be raised, and the skin is changed in 
texture, and there is apt to be a lilac ring about it. In 
chloasma the patch itself is dark with a convex border, 
while in lencoderma the border of the pigmentation is 
concave. The concave border of the pigmentation will 
also distinguish the disease from chromophytosis, which 
too is scaly. The normal sensation of the patches dis- 
tinguishes them from leprosy, in which the patches are 
anaesthetic. 

Treatment. Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
faradism may be tried, and nerve tonics given. We must 
content ourselves with making the patches less evident by 
removing the pigment from about them by the means 
given under Chloasma. Or we can stain the patches so 
'Jour. Cutan. and Ven. Dis., 18S3, i., 274. 



LEUKOPLAKIA. 351 

that they shall be less white, as by the use of walnut 
juice. Besnier and Doyon believe that they have cured 
cases in young subjects by the prolonged use of bromide 
of potassium internally, and saline or bromo-iodide baths 
externally, with or without injections of pilocarpine. 

Leucokeratose. See Leucoplakia. 

Leucopathia. See Leucoderma. 

Leucopathia Unguium, or Leuconychia. This affection 
consists in the appearance of white spots in the nail, which 
originate in the lunula, and gradually approach the free 
end of the nail as it grows forward. Sometimes these take 
the form of stripes or lines. Rarely the whole nail is 
affected. The nail-substance is otherwise unaltered. The 
spots are thought to be due to air-spaces in the nail-sub- 
stance. M. L. Heidingsfeld 1 believes that they are due to 
a disturbance in the growth, development, or keratinization 
of the matrix cells in their change to nail-structure. Why 
these occur we do not know. Possibly there may be a 
process of fatty degeneration of the nerve-cells and subse- 
quent absorption of the fat. (Taylor.) Or they may be 
caused by pressing back the nail-fold. They are common 
in the young, and coincident with white spots in the teeth. 
(Hutchinson.) They very often are noticed after fevers 
or other lowered conditions of health. . Nothing can be 
done for this deformity except caring for the general health 
of the patient and stopping any bad habit. 

Leucoplakia. This is an affection of the mucous mem- 
brane of the tongue, lips, inside of the cheeks, and vulva, 
that has been described under the names psoriasis buccalis, 
ichthyosis linguse, leucokeratosis buccalis, and tylosis lingua?. 
It occurs in the form of ivory-white or bluish-white, glis- 
tening, irregularly shaped patches upon the mucous mem- 
branes that may be a little elevated. To the touch and 
tongue they feel rough. They may give rise to no dis- 
comfort, or they may interfere with chewing and speaking. 
They may be fissured or papillomatous. There is sometimes 
salivation. They are caused by smoking, or occur in 

1 Journ. Cutan. and Gen.-Urin. Dis., 1900, xv., 490. 



352 DISEASES OF THE SKIN. 

syphilis, psoriasis, lithsemia, stomachic or intestinal catarrh, 
diabetes, and disturbed nervous influences. Sometimes 
they arise without assignable cause. 

Diagnosis. Leucoplakia differs from mucous patches 
in its more chronic course and slight tendency to ulcer- 
ation. Lichen planus, when occurring in the mouth, re- 
sembles the disease very strongly, but takes the form of 
rings, festoons, and disks, and the typical lichen papules 
can be found on the skin. 

Treatment. It is very essential that tobacco be given 
up if the patient has been in the habit of using it. It is 
also necessary to address remedies to the cure or relief of 
any lithsemic or digestive disorder; and to have the teeth 
put and kept in good order. An antisyphilitic treatment 
may be tried, but is of doubtful value. Sometimes a 
patch may be removed by the daily application of pure lactic 
acid ; or one-half per cent, solution of bichloride of mer- 
cury ; or ten to thirty per cent, solution of salicylic acid ; 
or one per cent, of chromic acid ; or two to ten per cent, 
of bichromate of potash ; or by galvano- or actual cau- 
tery. S. Sherwell has had good success with the acid 
nitrate of mercury. Great care must be had in its use, the 
surrounding parts being isolated by means of absorbent 
cotton, and an alkali held ready to neutralize any of the 
acid that has gone beyond the intended part, as well as to 
apply to the cauterized surface after a few moments. It 
is a very painful procedure. Hyde advocates the use of 
the dental burr after the injection of cocaine. 

Prognosis. It is a very obstinate disease. Patches 
not infrequently take on a cancerous change. 

Lichen Annularis. This affection is described by James 
Galloway 1 as occurring as small nodules in the neighbor- 
hood of the knuckles of the hands. The lesions form 
circular or crescentic patches that have a pale, ivory-like, 
elevated border raised from one to two millimeters. They 
are smooth and appear like deep-seated infiltration of the 
cutis. Inside of the border the lens shows that the normal 
wrinkles of the skin are partially obliterated. The disease 
1 Brit. Journ. Dermat., 1899, xi., 221. 



LICHEN PLANUS. 353 

advances at first slowly and then more rapidly. It is 
thought to be caused by some toxin, possibly that of gout. 
It is curable by tonics internally, and two to ten per cent, 
salicylic acid externally. 

Lichen Circinatus. See Seborrhcea. 

Lichen Moniliformis. See Lichen planus. 

Lichen Pilaris. This term is usually used as a synonym 
of keratosis pilaris. But Crocker describes it as a separate 
disease, the lichen spinulosus of Devergie. 

Symptoms. It develops acutely or subacutely in crops. 
It consists in an eruption of pinhead-sized, red, conical 
papules, in the center of which is a horny spine projecting 
about one-sixteenth of an inch. These spines can be 
picked out, and leave a depression in the papule. After a 
time the redness subsides and the papule becomes the color 
of the skin. The papules are crowded together in patches, 
which are round or large and irregular in outline. They 
occur in few or many regions and are symmetrically dis- 
tributed. The face, upper parts of chest, hands, and feet 
are usually exempt. They give a nutmeg-grater sensation 
to the hand when passed over the patches. There is little 
or no itching. 

Etiology. Children are the chief subjects of the dis- 
ease, boys more often than girls. 

Diagnosis. It differs from keratosis pilaris in its spines, 
its inflammatory redness, acuteness of outbreak, and its 
patchy character. 

Treatment. Alkaline baths and linimentum, saponis 
well rubbed in will cure the disease. If there is much 
inflammation, it is best to rub in oil instead of the soap 
liniment. 

Lichen Planus. A chronic disease of the skin charac- 
terized by the eruption of smooth, waxy, angular, umbili- 
cated, red papules, that tend to form scaly, lilac-colored, 
elevated and infiltrated patches specially upon the flexor 
surfaces of the wrists and the inside of the knees. 

While the testimony from skilled observers is over- 
whelming that lichen planus papules may occur with lichen 

23 



354 



DISEASES OF THE SKIN. 



ruber, and while some cases of lichen ruber have developed 
after and together with lichen planus, still we see so many 
cases of the latter occurring by itself that it merits a special 
description. In this country and in England lichen planus 
is far more frequent than is lichen ruber, and is regarded 
as a separate disease. While the latter occurred but 62 
times in 309,406 cases, the former occurred 918 times in 
the same number of cases, according to the statistics of the 
American Dermatological Association for 1897. 



Fig. 45. 




Lichen planus. (Fox. 1 ) 



Symptoms. The disease begins as an eruption of small 
purplish- or crimson-red, angular, flat, slightly raised 
papules, varying in size from one-sixteenth to one-sixth 
of an inch in diameter. A horny plug is sometimes seen 
in the center of a papule protruding more or less above 
the surface of the skin. When found it is regarded by 
some observers as a marked characteristic of the disease. 
The surface of the papules is smooth and shiny, " waxy- 
looking," and they have a small depression in the center. 
When fully developed the papules have on them either 
gray striations, or the whole papule is gray excepting a 
rosy edge. This grayness is characteristic. The papules 

1 G. H. Fox : The Skin Diseases of Children. New York, 1897. 



LICHEN PLANUS. 355 

may remain discrete, and be disseminated over a larger or 
smaller area ; or they may arrange themselves in rows, or 
aggregate themselves into patches, the single papules dis- 
appearing. The single papules are not scaly, the patches 
are slightly so. The patches may be small, and if so 
there is apt to be a well-marked depression in their center, 
and their shape is round or oval. The larger patches 
have no definite shape nor depression, but are well defined 
and elevated. Characteristic single papules will be found 

Fig. 46. 





Lichen planus. (Fox.) 

scattered about in the neighborhood of the patches. The 
color of the patches is characteristic, and may be defined 
as lilac. It is an important aid in diagnosis. Both the 
papules and patches on disappearing leave behind pig- 
mented, slightly atrophic spots, which, after a time, fade 
away. It is still a moot-point as to whether the indi- 
vidual papule enlarges peripherally or not. Like those of 
psoriasis, the papules of lichen planus may appear upon 
scratched surfaces. 

The disease is most often met with upon the anterior 
surface of the wrists and forearms, and upon the inside of 



356 DISEASES OF THE SKIN. 

the knees, the former being the favorite location. But it 
may occur anywhere, other favorite locations being the 
flanks, lower part of the abdomen, and the calves, and it 
may involve a large part of the body, though it rarely be- 
comes general. The mucous membranes of the lips and 
mouth are affected, and the disease then appears as white 

Fig. 47. 



Lichen ruber moniliformis. (After Taylor.) 

spots difficult if not impossible of diagnosis without 
the occurrence of the typical eruption on the integument. 
The involvement of the mucous membranes is rarely re- 
ported. It is probably more common than is supposed, 
because the mouth is seldom inspected, as the lesions give 
rise to no discomfort. As a rule, there is more or less 



LICHEN PLANUS. 357 

symmetry shown in the disposition of the efflorescences ; 
and pruritus, which sometimes is marked. The general 
health is often unaffected, but, on the other hand, many 
of the subjects of the disease are not in perfect condition 
when the disease begins, and not a few others become 
greatly broken down on account of the loss of sleep and 
continual discomfort caused by the pruritus. The course 
of this disease is chronic, and new outbreaks are liable to 
occur. True relapses usually do not occur when the disease 
is once cured. 

Kaposi 1 has described a unique form of this disease 
under the name of lichen ruber moniliformis, in which the 
typical lesions became transformed into keloidal nodes ar- 
ranged in lines. (Fig. 47.) The nodes were in some places 
as large as cherries with their bases confluent and their 
upper parts separated by furrows. The cases of this sort 
that I have seen in this country occurred in what were 
rather lichen ruber acuminatus or pityriasis rubra pilaris. 
Unna 2 describes what he names lichen obtusus, a form of 
papule midway between the acuminate and the plane. 
They are large and waxy, discrete, often convex papules, 
frequently bluish- white, not scaly, and but slightly itchy. A 
lichen verrucosus and a lichen hypertrophicus have also been 
described. Hallopeau and others have reported cases in 
which angular flat papules of white color occur, under the 
name of lichen planus atrophicus, seu sclerosus, seu morphoe- 
icus. It is met with on the upper part of the chest and 
arms. White papules are seen in colored races. Lichen 
planus striatus occurs as a long band, usually upon the 
inside of the thigh, sometimes extending the entire length 
of the limb. Pemphigoid eruptions occasionally occur as 
part of the disease. Crocker, who at one time described 
an infantile form of the disease in which the papules come 
out acutely in groups, acuminate at first, but soon becom- 
ing flat, angular, and red, changing to purple, now regards 
it as merely a miliaria rubra. 

Etiology. We know no more about the causes of 
lichen planus than we do about those of lichen ruber. A 

1 Vierteljahr. f. Dermat. u. Syph., 1886, xiii., 571. 

2 St. Petersburg, med. Wochenschr., 1884, i., 447. 



358 DISEASES OF THE SKIN. 

neurotic element is marked in many of the cases, and 
cases have been reported in which the papules were dis- 
tributed along the course of a nerve. 1 Nervous exhaus- 
tion, rheumatic sweating, and checking perspiration are 
given as causes. Its subjects are mostly adults, many of 
them otherwise in good health. It is probable that a 
toxaemia of some sort is the foundation of the disease. It 
is more frequent in women than in men in this country 
and in England, though in Austria the reverse obtains. 

Pathology. " In the plane form the process appears 
to be inflammatory, beginning usually round a sweat duct 
in the upper part of the corium, with subsequent thicken- 
ing of the rete and enlargement of the papilla? by down 
growth of the interpapillary processes." (Crocker.) The 
fact that the mucous membranes are affected is brought 
forward as an objection to the view that the process begins 
in the sweat duct. Robinson thinks that the process be- 
gins as an inflammation of the papilla? and upper part of 
the corium. The form of the papule is determined by 
the shape of the so-called " skin fields." 

Diagnosis. An eruption of flat, shiny, angular, um- 
bilicated papules of a lilac color showing grayish striations 
situated on the anterior surfaces of the wrists can be noth- 
ing but lichen planus. These same characteristics are 
diagnostic anywhere on the body, and sufficient to distin- 
guish the disease from eczema and psoriasis. Moreover, 
eczema will show a tendency to moisture, or the papules 
will undergo change ; and psorieisis will be almost sure 
to have characteristic patches upon the elbows and knees, 
covered with more abundant white and ofttimes thick 
scales. Syphilis sometimes bears a strong resemblance to 
lichen planus, but itching is less marked, its eruption is 
more polymorphous, and its color is more that of raw ham. 

Treatment. In the treatment of lichen planus, nerve 
tonics or sedatives and attention to the general health as 
well as to the hygiene both of the body and mind, are our 
most reliable agents. Arsenic is useful in some cases. 
Morris speaks highly of bin iodide of mercury in the initial 
dose of one-tenth of a grain, which is to be gradually in- 
1 Mackenzie: Brit. Med. Journ., 1884, ii., 1077. 



LICHEN RUBER AGUMINATUS. 359 

creased. Antipyrine, phenaoetine, and the spinal douche 
render good service. Alkaline diuretics sometimes do well, 
as the acetate of potash. Boeck and R. W. Taylor speak 
well of fifteen-grain doses of chlorate of potash fifteen 
minutes after eating, followed in a quarter of an hour by 
twenty drops of dilute nitric acid in a wineglassful of 
water. In obstinate cases change of scene in travel often 
cures when other measures fail. Locally stimulants, such 
as tar, pyrogallol, and chrysarobin, will prove serviceable. 
Unna's ointment, as given under lichen ruber acuminatus, 
is widely used. Touching the papules with pure carbolic 
acid may be tried. In acute cases alkaline lotions will 
allay irritation. Thymol and naphtol may be tried as in 
lichen acuminatus. In chronic cases Hardaway recom- 
mends : 

R Saponis olivse prsep., §iv; 100 

£! eiru . sc 3' I aa£j; aa 25 

Glycermi, j OJ ' 

01. rosmarini, Hiss; 4 

Alcoholis, ad §viij ; ad 200 

well rubbed in with a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. Some 
cases in which the skin is very irritable are best treated 
by means of prolonged simple or medicated emollient 
baths. Jacquet and other French dermatologists report 
excellent results from the use of spinal douches of water 
of varying temperature and force. 

Prognosis. The prognosis is generally favorable, 
though the disease is often very obstinate. 

Lichen Polymorphe Chronicuie. See Prurigo. 

Lichen Ruber Acuminatus. Though it is many years 
since Hebra first described this disease, dermatologists are 
still undecided as to many of its essential features, such 
as whether lichen planus is but a form of lichen ruber 
acuminatus, or a disease sui generis; and as to whether 
the separate lesion of lichen ruber increases peripherally 
or not. In this country the acuminate form of the disease 
is very rare, only fifty-two cases having been reported to 



360 DISEASES OF THE SKIN. 

the American Dermatologies! Association for sixteen years 
out of a total of 204,866. While in Europe lichen planus 
is considered as only a form of lichen ruber, in this 
country and in England it is regarded by probably the 
majority of the dermatologists as a separate disease, and 
will be described as such in this book. On account of 
the diversity in the descriptions of lichen ruber, the one 
here given is taken from Hebra and Kaposi. 1 

Lichen ruber, or lichen ruber acuminatus, is a chronic 
progressive disease of the skin marked by an eruption of 
small, red, conical papules tipped with a scale. These 
tend to run together and form lines, or diffused, red, scaly, 
infiltrated patches. 

Symptoms. The disease begins as a diserete eruption 
of millet-seed-sized, slightly scaly papules, that cause but 
little itching, and therefore are accompanied by but few 
excoriations. The papules may be bright or brownish 
red, conical, hard, covered with an adherent, dry, white 
scale, and imparting, when they are present in a sufficient 
number, a rough feeling to the touch. Or they may be 
pale red, waxy, smooth, rounded, and with a small angu- 
lar depression in their center. The first outbreak may be 
scattered about the whole trunk and extremities, though 
somewhat more abundant on the flexor surfaces of the 
latter. Or it may be limited for a long time to a single 
region, such as the leg or genitals. After a time the 
eruption becomes general by the appearance of new pap- 
ules either at the periphery of the first patch, or between 
the original papules, or irregularly over all. The single 
papules never increase in size during their whole course. 
After a time the papules crowd together, and melt into 
each other and form continuous, red, infiltrated patches of 
various sizes and shapes, whose surfaces are like shagreen 
leather or covered with scales. 

This is the most common course. Sometimes, however, 
the new papules appear in manifold circular rows about the 
older ones. The older ones sink in, disappear, and leave 
a darkly pigmented depression. The thus formed patches 
arc usually on the extremities. 

1 Lehrbuch der Hautkrankheiten, 1872. 



LICHEN RUBER ACUMINATUS. 361 

In a fully developed case the skin is everywhere red- 
dened, scaly, and thickened, and the movements of the 
joints are greatly interfered with, so that they are held in 
a semi-flexed position. The thickening of the skin is 
specially marked on the palms, soles, fingers, and toes, 
and here rhagades are prone to form. The nails are 
thickened, uneven, brittle, broken, opaque, yellowish- 
brown ; or they are represented only by thin horny plates. 
The coarse hair of the head, axilla?, and pubes is unaf- 
fected. Kaposi, in the third edition of his book, says 
that a defluvium capillorum takes place. 

The subjective symptoms are itching and a gradual pro- 
gressive interference with nutrition. At first the patient 
may feel quite well, but when the whole body is affected 
he falls • into a general marasmus, and at last dies from 
the effects of the disease. 

So far Hebra. Subsequent observers have reported 
the occurrence of a bullous eruption in the course of the 
disease. 

Etiology. The cause of the disease is obscure. It 
affects all ages and conditions, but is most frequent in the 
male sex — about two-thirds of the cases. By many the 
disease is considered to be a neurosis. 

Diagnosis. The disease must be differentiated from 
psoriasis, eczema, pityriasis rubra, pityriasis rubra pilaris, 
and lichen planus. From psoriasis it differs, when in 
the early stages, in that its papules do not enlarge into 
the large, characteristic psoriatic papules and patches ; in 
the later stages there are less scaling than in psoriasis uni- 
versalis, and more thickening of the skin ; and the palms 
and soles are far more profoundly diseased. From eczema 
it differs in that its papules neither undergo involution 
nor change into vesicles. Moreover, it does not itch so 
much, and there is never any moisture. From pityriasis 
rubra it differs in the greater thickening of the skin, and 
in its scaling, which is not in the form of thin plates or 
furfuraceous desquamation. From pityriasis rubra pilaris 
it is said to differ in being less scaly, in affecting the flexor 
surfaces by preference, in the darker color of the eruption 
from the first, in being more itchy, and in the profound 



362 DISEASES OF THE SKIN. 

constitutional disturbance. Nevertheless the opinion is 
gaining ground that the two diseases are identical. From 
lichen 'planus it differs in that it does not have its favorite 
locations upon the flexor surface of the wrist and inside of 
the knees, in having conical and not flattened papules, in 
not forming lilac-colored angular patches, and in a more 
frequent general involvement of the skin. 

Treatment. Arsenic, by the mouth or hypoder- 
mically, is the drug upon which most reliance is placed for 
the cure of this disease. The drug must be pushed up to 
its limit of toleration, and given continuously for a long 
time, and for some weeks after the disappearance of the 
eruption. The hypodermic method is very painful. The 
external treatment is by means of tar, if not too irritat- 
ing ; or we may simply address ourselves to the relief of 
the itching by means of carbolic acid, one or two drachms 
to the pint of olive oil or pound of vaseline. Crocker 
speaks well of thymol or naphtol, gr. x to gij to the 
ounce of vaseline. Unna's ' treatment has proved ser- 
viceable in many hands. He keeps the patient in bed 
between woollen blankets, and has him rubbed every 
morning and night with the following : 

B Ungt. zinci oxid. benzoat., .^iv ; 5001 

Ac. carbolici, Biv; 20 

Hydrarg. bichlor., gr. ij-iv ; 0.5-1 1 M. 

For the ointment of oxide of zinc, diachylon ointment 
may be substituted ; or a mixture of oil, lime-Mater, and 
white bole may be used instead. Where the corneous 
layer is very thick, two drachms and a half of chalk may 
be substituted for the bole. 

Prognosis. The course of the disease is essentially 
chronic. Even when a cure is effected, relapses are liable 
to occur. Hebra at first said that all cases were fatal, but 
the use of arsenic and increased experience in the treat- 
ment of the disease have greatly modified his gloomy 
prognosis. 

Lichen Scrofulosorum or Scrofulosus. A disease of the 
1 Monatshefte f. prakt. Dermat., 1892, i., 5. 



LICHEN SCEOFULOSORUM. 363 

skin occurring in strumous subjects, consisting in an erup- 
tion of small pale papules that tend to group in round or 
half-moon-shaped figures upon the abdomen, sides of the 
chest, and flanks. It is one of the so-called tuberculides. 

Symptoms. It occurs in the form of pin-point- to pin- 
head-sized, grouped, conical papules, which may be of the 
color of the skin, or pale red or fawn-colored. These 
papules occur around the hair follicles and form small 
round groups, or circles or segments of circles, upon the 
abdomen, sides of the chest, flanks, and neck in adults; 
and upon the extremities in children. They are some- 
what scaly, but give rise to no inconvenience, so that they 
are often overlooked. In some cases the papules are so 
numerous that the groups lose their distinctive shape, and 
large surfaces are covered, giving the skin a dirty-brown 
color. Many disseminated and discrete papules are scat- 
tered over the body outside of the patches. Acne pus- 
tules may form ; and a brown pigmentation of the face 
has been observed in some cases. The papules finally 
undergo absorption, desquamate, and leave transitory yel- 
lowish pigmentation. The disease runs a chronic, slow 
course. Eczema may complicate matters. Keratosis 
pilaris is frequently well marked upon the limbs. 

Etiology. The great majority of the subjects of this 
disease present evidences of scrofula. A few are robust. 
Some are phthisical, especially the children. The disease 
is most common in childhood, and is very uncommon 
after the twenty-fifth year of life. It is thought by many 
authorities to be a tubercular disease, due to the toxins 
of tuberculosis. Tubercle bacilli are not found in the 
papules. 

Diagnosis. The disease must be differentiated from 
papular eczema, the papular syphilide, lichen ruber, a 
punctate psoriasis, and keratosis pilaris. Eczema differs 
from it in greater itching, in the brightness and rapid 
development of the papules, and in its tendency to vesicu- 
lation or moisture. The papular syphilide is of darker 
red color, much larger, and more polymorphous ; the pa- 
tient's age is usually greater, and the history and course 
of the eruption will soon decide the diagnosis. Lichen 



364 DISEASES OF THE SKIN. 

ruber has darker papules, which do not group in circles 
and segments of circles ; they itch, and tend to involve the 
whole surface. The patients are more often adults, and 
there is a profound constitutional disturbance. Psoriasis 
itches, is abundantly scaly, and its papules soon enlarge 
and form characteristic patches. Keratosis pilaris affects 
the extensor surfaces of the limbs by preference, each 
papule is plainly about a hair, and the papules do not 
group. A curled-up hair will often be found in the center 
of the papule. 

Treatment. The persistent use of cod-liver oil both 
internally and externally will cure the disease. The 
syrup of the iodide of iron or the iodide of starch may 
be given with the oil. Good hygiene and food are valu- 
able adjuncts. For the cod-liver oil, which is disagreeable 
for external use, other oils, such as cocoa-butter, may be 
used ; or vaseline with or without oil of cade. Crocker 
recommends the addition of liq. plumb, subacetatis, Tflxv, 
or thymol, five grains to the ounce of vaseline. The dis- 
ease tends to get well of itself. 

Lichen Simplex. See Papular eczema. 

Lichen Spinulosus. See Lichen pilaris. 

Lichen Tropicus. See Miliaria. 

Lichen Urticatus. See Urticaria. 

Lineae Albicantes. See Atrophoderma. 

Linsenflecken. See Lentigo. 

Liodermia Essentialis. See Atrophoderma pigmento- 
sum. 

Lipoma is a fatty tumor. 

Liver Spot. See Chloasma. 

Lombardian Leprosy. See Pellagra. 

Lousiness. See Pediculosis. 

Lues. See Syphilis. 

Lupoid Acne. See Acne frontalis and Lupus miliaris. 



LUPUS ERYTHEMATOSUS. 365 

Lupus Erythematosus. Synonyms : Seborrhoea conges- 
tiva; Lupus superficialis ; Lupus sebaceus; Lupus ery- 
thematodes ; Scrofulide erythemateuse, or Ery theme cen- 
trifuge (Fr.) ; Dermatitis glandularis erythematosa (Mori- 
son) ; Ulerythema (Unna). 

This is a chronic disease of the skin, occurring in vari- 
ously sized, slightly elevated, scaly, red patches which show 
a strong tendency to the production of atrophic scars. 

Symptoms. There are two varieties commonly de- 
scribed, namely, the circumscribed or discoid, and the dif- 
fuse, or disseminated, or aggregated. To these some of 
the English writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 
met with. It occurs generally on the face, specially upon 
the sides of the nose and the cheeks, the scalp, and the 
ears ; more rarely upon the hands and feet ; and still more 
rarely on other parts of the body. It begins by the ap- 
pearance of several isolated or grouped red spots slightly 
elevated, of pinhead to split-pea size, with a thin adherent 
scale upon them. Some of these spots may be depressed 
in the center. When the scale is removed there will be 
found upon its under side a delicate projection formed by 
a plug of sebaceous matter that dipped down into the 
mouth of the sebaceous gland. The mouth of the gland 
will be found patulous. These spots increase in size by 
peripheral extension to form disc-shaped figures of varying 
size ; neighboring ones will coalesce, and thus patches will 
be formed, also covered with the fine grayish or white ad- 
herent scales. Now when the scale is raised a number of 
the characteristic prolongations will be found on its lower 
side. The margins of the patches are slightly raised, but 
the middle parts undergo involution, are lower than the 
margins, and after a time are apt to become cicatricial, the 
skin being atrophied. The scar-tissue thus formed is thin, 
delicate, and white, never puckered or deforming. 

The color of the patches is red, but of a peculiar hue 
that is characteristic, and perhaps can be best defined as 
violaceous. There is never any moisture connected with 
the disease. Burning or itching may or may not be pres- 
ent. The patches are of indefinite duration — months or 



366 DISEASES OF THE SKIN. 

years. At times they disappear of themselves, and do not 
leave scars, but the rule is that scars are left. The extent 
of the disease varies greatly, as well as the shape of the 
patches. The greater part of the face may be involved, 
or there may be only a single patch. Usually the eruption 
is symmetrical. A characteristic location for the disease 
is upon the back and sides of the nose and the contiguous 
parts of the cheeks, forming what has been fancifully called 
a butterfly, the ridge of the nose representing the back of 
the animal, and the cheeks its wings. Sometimes gyrate 
figures are formed. The mucous membranes and the ver- 
milion border of the lips may be affected, presenting patches 
with punctate excoriations of red color, or spotted with 
grayish masses of exudation and superficial cicatrices. 
Occurring upon the scalp it leads to permanent loss of hair 
from well-defined patches, and the same may be said of it 
as it occurs on other hairy parts. The disease may become 
stationary after a time. Relapses are liable to occur. The 
general health is unaffected. 

The (J iff use or disseminate form is a more acute process, 
and exceedingly rare in this country. In it the patches 
may appear suddenly or slowly develop. They are from 
pinhead to finger-nail size, slightly elevated, reddish brown, 
hyperaemic, and hard ; they pale under pressure, and are 
attended with heat and burning. In this stage they resem- 
ble an urticaria or the papular stage of eczema. There 
may be from twenty to a hundred or more of them crowded 
together upon the face and scattered over the body. Many 
of them may disappear in a few days without leaving any 
trace, while others will remain and become characteristic 
patches of lupus erythematosus with depressed cicatrices. 
The individual lesions do not increase in size, and the 
patches are formed by aggregations of single lesions. The 
eruption may be accompanied by a high degree of inflam- 
mation, exudation, and crusting, or even by bulla?. There 
may be deep, painful subcutaneous tumors in the joints 
and glands at first, over which characteristic patches will 
form. In some acute cases the development of the patches 
is accompanied by fever, osteocopic pains, and nocturnal 
headaches, and in some cases the patient will pass into a 



LUPUS ERYTHEMATOSUS. 367 

typhoid condition and die of some lung complication. Or 
there may be a persistent inflammation of the face, erysip- 
elas perstans, which may lead through a typhoid state to 
death. There may also be swelling of the parotid glands 
and of various lymphatic glands. In some cases the disease 
bears a close resemblance to chilblain. 

The telangiectic form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection 
shows to be clue to dilated vessels, and is commonly located 
symmetrically upon the cheeks. Upon pinching up the 
skin it will be found to be markedly thickened. Some few 
comedones may be present. There is no desquamation. 

Etiology. About two-thirds of the cases occur in 
women. It seldom occurs before puberty, though Kaposi 
has seen a case in a child of three years. Beyond these 
facts we know but little of its etiology. The French re- 
gard it as a scrofulous affection which, in the light of 
modern pathology, is regarded as tubercular. While noth- 
ing suggesting its relation to a tuberculous process has 
ever been found in the skin, still, as not a few patients 
show other symptoms of a general tuberculosis, such as 
swollen or broken-down glands in the neck or cicatrices 
from the same, or give a history of tuberculosis in other 
members of their family, there is a growing opinion that 
the disease is a species of tuberculosis of the skin due to 
the toxins of that disease. Crocker suggests a feeble 
circulation and prolonged exposure to great cold or heat 
as possible causes. It has been seen to follow upon frost- 
bite and sunburn. It would also seem that those who are 
subjects of seborrhoea are predisposed to the disease. 

Pathology. In spite of much careful study the exact 
pathology of the disease is still undetermined. J. A. For- 
dyce and O. H. Holder 1 believe that the process is due to 
embolism of the small arteries, arising either on account 
of an alteration in the blood due to a toxin, or to some 
change in the walls of the vessels, or to a thrombus brought 
from some distant part. In the majority of cases the 
earliest manifestations of the disease are capillary obstruc- 
tion and then an infiltration of round cells in the middle 
* Med, Bee, 1900, lviii., 41, 



368 DISEASES OF THE SKIN. 

of the lower zone of the corium, the sebaceous glands and 
hair follicles being secondarily involved. The cicatricial 
scarring is the result of atrophic processes. Robinson 1 
regards the disease as a local infectious process, a granu- 
loma, inflammatory in character. This view is held also 
by Schoonheid. 2 

" Diagnosis. The disease must be differentiated from 
lupus vulgaris, eczema, rosacea, psoriasis, and syphilis. A 
typical case occurring upon the face in the form of red 
patches, with fine cicatrices in the center, and covered with 
a delicate white or grayish adherent scale, from the under 
side of which are a number of projections, offers no 
difficulty in diagnosis. Lupus vulgaris differs from lupus 
erythematosus in occurring before puberty, in showing no 
disposition to symmetry, in the presence of apple-jelly 
tubercles, in being a deep-seated disease, and in leading to 
far more disfiguring cicatrices. Eczema never leaves scars, 
is prone to exudation, itches, its scales do not show pro- 
longations from the under side, and its patches undergo 
more rapid and varied changes. Psoriasis will be pretty 
sure to show characteristic patches covered with thick 
scales, and never causes scarring or leads to permanent 
loss of hair. Rosacea is largely composed of dilated 
blood vessels, occupies the middle third of the face, often 
presents superficial pustules, does not leave scars, and is 
subject to frequent exacerbations. In syphilis a history of 
other lesions will be obtainable, there will be more evident 
infiltration, and the course of the lesions will be more 
rapid. The disseminate form of the disease is very difficult 
of diagnosis at first, but as soon as characteristic patches 
form the difficulty is removed. 

When lupus erythematosus occurs upon the scalp it 
causes a bald spot that may be mistaken for alopecia areata, 
but differs from it in its irregular shape, in the signs of 
inflammation in it, and in the cicatricial condition of the 
scalp it leaves. A microscopical examination of the hairs 
from about a patch will decide as between lupus erythema- 
tosus and /aims or ringworm. 

' Trans. Amer. Dermat. Assoc, 1898. 

2 Arch. f. Dermat. u. Syph., 1900, liv., 163. 



LUPUS ERYTHEMATOSUS. 369 

Tkeatment. Little beyond the care of the general 
condition of the patient upon general principles can be 
done for lupus erythematosus in the way of internal medi- 
cation. McCall Anderson advocates the use of iodide of 
starch, made by triturating twenty-four grains of iodine 
with a little water, and gradually adding one ounce of 
starch, rubbing them well together until the mass becomes 
deep blue in color. Of this a heaped teaspoonful, increased 
gradually, may be given three times a day in water or gruel. 
Iodide of potassium is also commended, as are phosphorus 
and salicylate of soda. 

Sometimes in the early stages alkaline washes, such as 
lotions of zinc or lead, may be used. Or one composed of 

R Zinci sulphat., 1 -- . -- „ 

Potassii sulphurat., f aa 3J ; aa 6 



Alcohol., 3iij ; 10 

Aquae rosse, ad %iv ; ad 100 



M. 



as in acnea and rosacea. Green soap or prepared olive 
soap, or its tincture, may be used in more chronic cases. 
This is often serviceable for the disease as it attacks the 
eyelids. The affected parts are to be well rubbed with it, 
using a piece of flannel. The process is to be repeated 
every few days. If the reaction is too great, a little oil 
or a glycerin lotion may be applied. Crocker advocates 
the addition of one or two drachms of the oil of cade to 
the ounce of the tincture of green soap. Carbolic acid, 
pure, applied to the patches, often acts admirably. It 
turns them white at first. The application is to be re- 
peated as soon as the crust falls. Fowler's solution £j in 
distilled water 3j, and spirits of chloroform two drops, ap- 
plied externally in the morning and evening, is sometimes 
efficacious. Resorcin, fifty per cent, aqueous solution, ap- 
plied once or twice a day until decided reaction takes place, 
and then cold Cream or calamine lotion used until the reac- 
tion subsides, is a good plan of treatment. The resorcin 
solution must be repeated when the reaction has subsided. 
Pyrogallic acid, ten per cent, in ointment, sometimes does 
well. N. Walker thinks that oxidized pyrogallol, one to 
two per cent, in acetone collodion, is the best means we 

24 



370 DISEASES OF THE SKIN. 

have; while others consider a combination often per cent. 
pyrogallol with forty per cent, of salicylic acid in collodion 
is better than anything else. Chloracetic acid ; oil of cade ; 
solution of naphtol, one percent.; resorcin, three to ten per 
cent, strength in solution or ointment ; tincture of iodine 
or iodide of glycerin ; caustic potash, one part to six or 
twelve of water, have their advocates. Hydronaphtol 
plaster, resorcin plasters of ten t<> twenty per cent. 
strength, and mercurial plaster are often excellent when 
persisted in. Sulphur or ichthyol in ointment or paste 
does well in some eases. Thilanin sometimes does well. 
H. Hebra has introduced the method of sopping the patches 
every fifteen minutes with pure alcohol containing four per 
cent, of menthol. The phototherapy of Finsen has done 
well in some cases. It must be used as described under 
lupus vulgaris. Liquid air acts like a caustic in these 
cases. All cases should be carefully watched that the reac- 
tion from our remedies does not go too far. If the remedy 
produces too much reaction, it must be stopped, a mild 
zinc lotion applied until the irritation subsides, and then 
the remedy is to be used again. 

If these superficial caustics do not cure, resort may be 
had to linear scarifications, making a series of cross-hatch- 
ings, taking care not to go very deep. The bleeding is 
to be checked by pressure and the application of carbolic 
acid, two drachms to the ounce. Limited surfaces must 
be taken at a time. Electrolysis by means of multiple 
punctures will sometimes give brilliant results. Some- 
times running the needle across the patch, making a num- 
ber of parallel insertions, will have a good effect. Erasion 
with a curette, galvano- or Paquelin cautery, and strong- 
escharotics, such as the acid nitrate of mercury, may have 
to be used in very obstinate cases, but not till all other 
means are exhausted, as they are apt to leave deep scars. 

Prognosis. The prognosis should be guarded, as the 
disease is a most obstinate one, and prone to relapses. A 
cure may, however, be effected by patient perseverance. 
It is wise always to tell our patients that scars are liable 
to be left, not only by the treatment employed, but by the 
disease itself. An accidental attack of facial erysipelas 



LUPUS VULGARIS. 371 

cured one case under my observation. The discoid form 
has little effect upon the health of the patient, but the dis- 
seminated variety not infrequently ends fatally. 

Lupus Exedens. See Lupus vulgaris. This term is 
sometimes applied by surgeons to epithelioma. 

Lupus Exfoliativus, seu Exulcerans, seu Hypertrophicus. 
See Lupus vulgaris. 

Lupus Miliaris or Lupoid or Adenoid Acne. See Acne 
necrotica. 

Lupus Pernio. This disease affects the uncovered parts, 
hands, face, and specially the ears, nose, and upper lip. 
It is ill defined, and extends over large surfaces. It is 
marked by cyanosis, telangiectasis, infiltration of the skin, 
diffuse tumefaction, Assuring of the skin, and superficial 
vesiculation. Slight ulcerations form that become cov- 
ered with crusts and last a long time. The old patches 
are studded with irregular cicatrices. It is a chronic dis- 
ease with no subjective symptoms. It occurs in lym- 
phatic subjects, and is distinct from the other varieties of 
lupus. 1 

Lupus Sclerosus. See Tuberculosis verrucosa cutis. 

Lupus Sebaceus, seu Superficialis. See Lupus erythema- 
tosus. 

Lupus Tuberculosus, seu Verrucosus, seu Vorax. See 
Lupus vulgaris. 

Lupus Vulgaris. Synonyms : Besides those given above, 
which merely describe certain stages or forms of the dis- 
ease, and are quite unnecessary to be remembered, we 
have : Noli me tangere ; Herpes esthiomenes ; (Fr.) 
Dartre rongeante, Scrofulide tuberculeuse, Esthiomene ; 
(Ger.) Fressende Flechte. 

This is a chronic neoplastic disease of the skin due to 
its invasion by the tubercle bacillus, and characterized by 
one or more brownish-red papules, tubercles, or infiltrated 
patches, that tend either to absorption or ulceration, and 
always leave scars. 

J Tenneson : Atlas de Musee de l'hopital St. Louis, p. 135, 



372 DISEASES OF THE SKIN. 

Symptoms. Lupus vulgaris usually begins in child- 
hood and upon the face ; the cheek and nose being the parts 
most usually affected. The initial lesion is a dark-red or 
brown pin-point- to pinhead-sized papule, which may be 
on a level with the skin, depressed below, or raised above 
it. There may be but a single papule, but usually there 
are a few of them either grouped or scattered. After a 
time slightly scaly patches will form by the coalescence of 
the lesions which have enlarged, into brownish-red, semi- 
translucent, smooth, shiny tubercles, or by the develop- 
ment of new lesions between the old ones. The shape of 
the patches is irregular. Rarely they are ring-shaped. 
The size of the patches varies greatly, but they are always 
elevated above the surface of the skin, of a dark-red color, 
and studded with the little brownish-red papules, or so- 
called tubercles. The appearance of these tubercles has 
been likened by Hutchinson to that of apple-jelly. There 
may be but one patch, or the whole face may be more or 
less covered with a number of them. Symmetry is not a 
feature of the disease, often only one side of the face being 
affected. Sometimes two or more patches will coalesce at 
their borders, their centers will fade out, or rather become 
atrophic, and a gyrate patch will form, creeping over the 
skin with a well-marked, elevated, dark-red border. The 
center of all the patches is lower than the border, and 
eventually is atrophic. The course of the disease is slow 
and chronic, and the fate of the patches varies greatly. 
For months or years they may remain absolutely quiet, 
and then show signs of activity by new lesions appearing 
about the edges of the patches or in the scar-tissue. The 
patches may entirely disappear, leaving a fine, smooth 
cicatrix ; this is rare without treatment. Or they may 
break down and form ulcers, which are irregularly rounded, 
shallow, with easily bleeding floors, and a moderate amount 
of purulent secretion that dries into a crust. This is the 
so-called lupus exulcerans, and is not very frequent in this 
country according to my experience. Sometimes upon this 
ulcerated surface papillary or warty growths will spring 
up, the so-called lupus papilfomatosus or verrucosa*. Some- 
times the infiltration of the patch is unusually great, and 



LUPUS VULGARIS. 373 

then we have lupus hypertrophicus. Most commonly 
we have a non-ulcerated, exceedingly chronic infiltrated 
patch with areas of cicatricial tissue scattered through it. 
When the disease attacks the end of the nose, it will cause 
it to shrink up and convert it into cicatricial tissue. When 
the ear is diseased, it also shrinks up so as to be half the 
size it was originally. These changes are due either to 
ulceration or to the gradual absorption of the lupus tuber- 
cles that they all undergo. 

While the face is the site of predilection of lupus, it may 
also occur upon any part of the skin of the body, as well 
as upon the mucous membranes. In this latter situation 
it is most often secondary to the disease elsewhere ; still it 
is often primary. Thus Bender 1 found that 30 T 3 ¥ per 
cent, of all his lupus cases began in the nasal mucous 
membrane. Pontoppidan also found the origin of the dis- 
ease to be the nasal mucous membrane in many cases. In 
the nose it frequently leads to perforation of the septum, 
and sometimes causes great deformity of the nose, but it 
does not attack the bones. All other mucous membranes 
may be attacked, the rectum and vagina being least often 
affected. Upon mucous membranes we do not see the same 
tubercles as on the skin, but papillary excrescences which 
form patches. They may be absorbed or ulcerate. The 
conjunctiva? may be involved primarily or secondarily. 
Epithelial cancer has developed in very rare instances 
upon the lupoid tissue itself, more commonly upon the 
scar tissue left by the lupus. Whenever it develops as a 
sequela of lupus its course is more rapid and its prognosis 
far more grave than is usually the case. Erysipelas is a 
not infrequent complication of lupus, and is sometimes 
curative in its action. Lupus of the extremities is often 
followed by permanent deformities and disabilities, and 
sometimes by tubercular lymphangitis. Implication of 
the lymphatic glands is exceptional in lupus, and then 
only in advanced cases. 

Etiology. Lupus has long been regarded as a mani- 
festation of scrofula. It is now demonstrated that it is a 
tubercular disease. It should be placed under the division 
1 Vierteljahr. f. Derm. u. Syph., 1888, xv., 891. 



374 DISEASES OF THE SKIN. 

of Tuberculosis cutis, but usage makes it advisable to con- 
sider it by itself. Many patients with lupus are plainly 
strumous; many, 55^ per cent, of SachV cases, are either 
tuberculous themselves or have a decided history of the 
occurrence of phthisis in their family. The phthisical 
history is far less pronounced in this country than it is in 
Europe. It is no uncommon thing for several members 
of the same family to have lupus. It is probable that we 
could find a close connection between lupus and infection 
with the tuberculous virus in all cases, were it practicable 
to do so. Another evidence of its tubercular origin is 
found in the nearly uniform reaction of lupus to tubercu- 
lin. It is much more frequent in females than in males, 
about sixty-two per cent, being in females according to 
Block's and Sach's statistics. It begins in more than half 
the cases before the fifteenth year. It may begin as early 
as the second year. It is almost always a disease of 
youth. 

Pathology. The pathology of lupus has been studied 
by many competent investigators. " It is a neoplasm of 
the granuloma class, and consists of a small-cell infiltration 
which begins in the deep part of the corium, and from 
thence gradually invades all the other skin structures," 
says Crocker. The tubercle bacillus is found in the tis- 
sues, though but sparsely. Inoculations have not always 
been successful, but in a goodly number of cases the inocu- 
lations have been followed by general tuberculosis, so as to 
warrant our belief in the tubercular nature of the disease. 
It has been suggested that as the bacilli are present in but 
a small number, the irritation of the tissues is due to the 
toxins produced by them. 

Diagnosis. Lupus is most commonly confounded with 
a tubercular or gummous syphilide. It may have to be 
differentiated from a scrofuloderm originating in a caseous 
gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosticated by the 
presence of the characteristic apple-jelly tubercles ; by its 
slow course ; by its history ; by the absence of all other 
signs of syphilis ; by its little tendency to ulceration ; by 
1 Vierteljahr. f. Derm. u. Syph., 1888, xiii., 241. 



LUPUS VULGARIS. 375 

the superficial character of its ulcers and their slight 
crusting ; and by its sparing the bones. If there is still 
any doubt, appeal may be made to the effect of treatment 
by means of the iodide of potassium and mercury, which 
will have no effect upon the lupus. As the scrqfuloderm 
is another manifestation of the tubercular diathesis and 
amenable to the same treatment as that of lupus, its dif- 
ferentiation is not so important. It, however, will begin 
about a caseous and broken-down lymphatic gland or 
gumma, will probably have sinuses, and no characteristic 
tubercles. An epithelioma begins usually after the thirty- 
fifth year ; has no tubercles ; and forms a deep ulcer with 
raised, hard, waxy edges crossed with dilated blood vessels. 
The diagnosis from lupus erythematosus is given in the pre- 
ceding section. Leprosy presents large tubercles which 
are ansesthetic, and this at once decides in its favor. 

Treatment. As lupus is a tubercular disease, and 
sometimes is followed by tuberculosis of the lungs, care 
must be given to the general health of the patient, and he 
must be placed in the best possible hygienic surroundings. 
His diet should be nutritious, and cod-liver oil, iodine, and 
iron should be given. But external treatment is of the 
greatest importance, and the disease must be gotten rid of 
root and branch. If a single diseased cell remains, the 
disease is sure to return. To effect its destruction surgi- 
cal procedures had best be resorted to. The Avhole patch 
or patches may be scraped out with the dermal curette, 
and this followed by a twenty-five or thirty per cent, pyro- 
gallol ointment for a week or ten days, and that in turn 
by mercurial plaster for another equal term. The pyro- 
gallol will cause free suppuration and destroy the cells left 
behind by the curette. A second or third course may be 
necessary. Piffard prefers to touch the base left after 
curetting with the galvano-cautery at a red heat. The 
wound is then to be packed with absorbent cotton. After 
about ten to fourteen days the crust and cotton will fall 
off and leave a soft, smooth, pliable cicatrix. Multiple 
scarifications have proved of great use. They may be 
made with a many-bladed instrument constructed for the 
purpose, or with a scalpel, or a knife shaped like a 



376 



DISEASES OF THE SKIN. 



butcher's cleaver (Fig. 48). They must go deep enough 
to penetrate all the softened tissue, but not to wound the 
sound parts. The resistance ottered by the healthy tissue 




Scurifying-knife. 



will be sufficient guide for this. The scarifications should 
be so made as to divide the tissues into little squares, thus : 



They may be repeated in five or six days, and need no 
after-treatment. This is Vidal's method. The individual 
tubercles may be bored out with Morris's double-screw in- 
strument, or with dental burrs and hooks dipped in pure 
carbolic acid, as proposed by Dr. George H. Fox. The 
galvano- or Paquelin cautery may be employed to destroy 
the disease. This will require the administration of an 
anaesthetic, while the former procedures do not require 
it, or at most anything more than local anaesthesia by 
means of cocaine. Multiple punctures by means of the 
galvano- or thermo-cautery at somber red-heat at one 
millimeter distance for small patches and linear scari- 
fications with cautery knife for large ones, followed by 
emplast, vigo, and repeated once a week, is Besnier's 
method. Electrolysis in multiple punctures or by pass- 
ing the needle through the patch or by means of a flat 
metallic button, is a useful mode of treatment. The 
current must measure three to five milliamperes, and it 
must be continued for five minutes, when the button is 
used. Auspitz recommends puncturing the patches in 
many places with a steel point dipped in carbolic acid. 
Lang 1 advocates excision of the patches when not too 
1 Dermat. Zeitsclmft., 1900, vii., 805. 



LUPUS VULGARIS. 377 

large, followed by grafting. He has operated in eighty- 
five cases, fifty-eight of which he was able to follow up. 
Of these, thirty-nine remained free from relapses. 

These surgical procedures have largely superseded the 
use of caustics, though the latter are valuable and may be 
used when the patient fears an operation. Arsenic may be 
employed in the form of a paste, such as Hebra's modifica- 
tion of Cosme's paste : 



B Ac. arsenios, gr. x ; 2 

Hydrarg. sulphureti rubri, 3J ; 12 

Ungt. aq. rosse, ad 3J ; 100 



50 
M. 



which is to be spread on lint or linen, applied evenly, and 
bound down firmly. It is to be left on for twenty-four 
hours, then removed and reapplied till ulceration is set up. 
It is painful. Vienna paste, of equal parts of caustic 
potash and unslacked lime ; or a chloride of zinc paste may 
be used, such as one part of zinc to three parts of starch. 
Both are painful. Many think highly of boring into the 
patch with the solid nitrate of silver stick. Salicylic acid, 
twenty to twenty-five per cent., in plaster or plaster-muslin, 
changed once or twice a day is good. It is well to combine 
creosote with the salicylic acid, two parts to one, to allay 
the pain caused by the acid. The local application of 
bichloride of mercury in solution (gr. j to .5j) to ulcerated 
forms, and in ointment to non-ulcerated forms, is com- 
mended by White and others. 

Unna x recommends painting with pure carbolic acid for 
from two to four days. He has also had good results 
with a salve-muslin containing one per cent, of bichloride 
of mercury, twenty per cent, of carbolic acid, and thirty- 
six per cent, of oxide of zinc. He 2 has also recommended 
the following procedure : Little sticks of hard wood are 
sharpened and then soaked for several days in a solution of 

R Hydrarg. bichlor., gr. xv ; 1 

Ac. salicylic!, ^iiss ; 10 

iEtheris sulph., %y] ; 25 

01. oliva?, ad giij ; ad 100 M. 



Monatshefte f. prakt. Dermat., 1891, xii., 341. 
Ibid., 1895, xxi., 281. 



378 DISEASES OF THE SKIN. 

A stick is forced into each tubercle, cut off close to 
the skin, and covered with gutta percha or carbolized 
mercurial plaster. After two days the plaster is removed, 
leaving a surface covered with a' thin layer of pus. The 
holes made by the sticks are enlarged and the sticks lie 
loose in them. The sticks are removed, the surface asep- 
tically cleansed, the holes filled with a powder of 

H Hydrarg. bichlor., gr. iss; 1 

Magnes. carbon at., ^iiss ; lol 

Ac. salicvlici, 3j gr. xv ; 5 

Cocain. nniriat., gr. viiss; ojo M. 

which is blown on with a powder-blower and worked in by 
the fingers or with a wooden spatula. The patch is again 
covered with the plaster for twenty-four hours, when the 
procedure is repeated for another' day. The subsequent 
treatment is by pyrogallol. 

Neither tuberculin nor tuberculin TR has proved as 
valuable as it promised. Only very few cases have been 
reported as cured by it. The inconvenience, depression, and 
sometimes fatal results from these remedies render them 
unfit for general use. 

The most recent treatments of lupus are by the Roentgen 
rays and phototherapy. Both these methods require ex- 
pensive apparatus and are very slow. The latter is known 
as Finsen's method. Both sunlight and electric light are 
used concentrated by means of a focussing apparatus upon 
the patch rendered bloodless by pressure with a convex 
glass. Each sitting by sunlight lasts two hours, by electric 
light one hour. The treatment must be repeated daily. 

Prognosis. The prognosis should always be guarded. 
Relapses after any plan are too often seen/ A scar must 
result both from the disease and its treatment. The pos- 
sibility of the development of a general tuberculosis must 
also be borne in mind, although many patients preserve 
throughout the course of the disease* a robust state of 
health. 

Lymphangiectasis. Varices of the dermal lymphatics 
may be superficial or deep ; and affect the trunk, the 
meshes, or the lacunae, though most commonly all parts 



LYMPHANGIOMA. 379 

of the vessels are diseased. When they are superficial 
they form ampullary swellings • at the surface of the skin 
which may be isolated or agglomerated. In size they vary 
from that of a millet-seed to that of a pea or larger. In 
color they" vary with that of the skin. They break more 
or less easily and discharge the lymphatic fluid. If deep, 
they Can be more readily felt than seen, or form upon the 
surface of the skin isolated or associated raised cords which 
run a; more or less tortuous course. After a time these 
also break and discharge lymph. 

Hallopeau and Goupil l describe under this title a dis- 
ease that they believe to be of tubercular origin, and that 
appears about a bony prominenee of the extremities as a 
diffuse tumefaction or a cushion-like elevation resembling 
varicose vein tumors. They eventually open and dis- 
charge pure lymph or lymph mixed with pus. Fresh 
tumors arise in the course of the lymphatics in an ascend- 
ing series ; also gummy nodes. The affected limb is swol- 
len, indurated, and of more or less somber red. The 
prognosis is grave, and the proper treatment undetermined. 

Lymphangioma, also called Lymphangiectasis, Lymphan- 
giectodes, Lupus Lymphaticus, and Lymphorrhagica Pachy- 
dermia, is an exceedingly rare disease. It consists, accord- 
ing to Crocker, in a number of minute, deep-seated 
vesicles, closely crowded together in irregularly outlined 
groups of from one-third to one-quarter of an inch in size. 
These groups are arranged irregularly with healthy skin 
between them, or a few scattered vesicles in the otherwise 
healthy skin. They are usually confined to a single small 
area. The vesicles are deep-seated with thick walls, some 
of them almost warty-looking. They are pin-point to 
hemp-seed size, colorless or straw-colored, or pinkish, and 
contain a clear fluid. Some have vascular stria? or tufts 
over them, others red clots, others contain extravasated 
blood. They run a chronic, non-inflammatory course, 
spreading slowly at the periphery, and tending to relapse 
if removed. Most of the few cases have occurred in males 
and begun in early childhood. 

1 Ann. de. derm, et de syph., 1890, i.> 957. 



380 DISEASES OF THE SKIN. 

The disease is of lymphatic origin, and the main feature 
is dilated lymphatic vessels. 

Fig. 49. 




Lymphangioma. (Epstein 1 ) 

The treatment consists in destruction by caustics, ex- 
cision, or electrolysis ; but relapses are liable to occur. 

A number of other rare affections of the lymphatics have 
been named lymphangioma. The present state of our 
knowledge in regard to them is by no means exact. One 
variety is named by Kaposi 

Lymphangioma Tuberosum Multiplex. This is a still more 
rare disease than lymphangioma, and consisted, in Kaposi's 
case, in the appearance all over the trunk and neck of 
hundreds of lentil-sized, rounded, brownish-red, smooth, 
glistening, disseminated, flat or elevated tubercles. They 
were firm and elastic, slightly painful, and upon some of 
them were dilated blood vessels. One or two other cases 
of the same kind have been reported by others. By 
some this disease is regarded as a species of benign cystic 
epithelioma. 

1 By permission from Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 214. 



MILIARIA. 381 

Lymphoderma Perniciosa. See Mycosis fungo'ides. 

Lymphorrhagica Pachydermia. See Lymphangioma. 

Lymphosarcoma. See Sarcoma. 

Maculae et Striae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Maculae Caeruleae. See Pediculosis vestimentorum. 

Madura Foot. See Fungous foot of India. 

Mai de la Rosa. See Pellagra. 

Mai Rosso. See Pellagra. 

Maladie des Vagabonds. See Pediculosis. 

Malignant Papillary Dermatitis. See Paget's disease. 

Malignant Pustule. See Pustula maligna. 

Malingering. See Feigned eruptions. 

Malleus. See Equinia. 

Mamillaris Maligna. See Paget's disease. 

Mask. See Chloasma. 

Measles. See Morbilli. 

Medicinal Eruptions. See Dermatitis medicamentosa. 

Melanoderma, seu Melasma. See Chloasma. 

Melastearrhee. See Chromidrosis. 

Melanosarcoma. See Sarcoma. 

Melanosis Lenticularis Progressiva. See Atrophoderma 
pigmentosum. 

Melitagra. See Pustular eczema. 

Mentagra. See Sycosis. 

Miliaria. Synonyms : Sudamina ; Lichen tropicus ; 
(Ger.) Frieselauschlag ; Prickly heat. 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is 



382 DISEASES OF THE SKIN. 

enough to distinguish two forms, namely, sudamina and 
lichen tropicus. 

Symptoms. Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile 
diseases, and occurs as an eruption of an immense num- 
ber of small, closely crowded, but discrete, bright, pearly 
vesicles entirely without inflammation or subjective symp- 
toms. They are most abundant on the trunk, especially 
upon its anterior plane, but may occur anywhere. After 
lasting a few days they are absorbed and disappear by 
drying up, possibly with some scaling, or they may rupt- 
ure and dry up. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 
pin-point, bright-red papules (miliaria papulosa); or of 
very small vesicles upon an inflamed skin (miliaria rubra) ; 
or the eruption may be a composite one of papules inter- 
spersed with vesicles and pustules. Whichever form it 
may assume, the lesions are present in great number, and 
closely crowded together, though not aggregated. It may 
involve the whole surface of the body, but is most com- 
mon on covered parts, and especially upon the trunk. The 
eruption is apt to become better or worse according to 
the changes in the temperature of the atmosphere. The 
disease may last in this way throughout the warm weather. 
It is no uncommon thing for furuncles to form, and even 
cutaneous abscesses. Itching, prickling, and burning are 
always annoying accompaniments. If the skin is much 
scratched, eczema may complicate the disease. The old 
nurse's "red gum," the strophulus of older writers, is a 
miliaria. Kaposi regards the disease as an eczema. 

Etiology. The cause of sudamina is retained sweat, 
owing, probably, to epithelium clogging up the sweat 
pores when sweating is stopped on account of the fever. 
When the fever passes and the sweat glands resume their 
function the rush of sweat to the surface raises up the 
epithelium over the pores into little vesicles. They soon 
give way and the trouble is over. Lichen tropicus is due 
to congestion about the sweat pores and irritation of the 
skin when profuse sweating is induced by too warm cloth- 



MILIUM. 383 

ing and hot weather. It is also suggested that checking 
a profuse sweat may cause it. It is seen most commonly 
in babies and fat people. It is noticeable in this city 
(New York) that the children who live near the river 
front and are a good deal in the salt water escape the 
disease, while it is very common in the rest of the tene- 
ment-house population. 

Diagnosis. Sudamina differs from vesicular eczema in 
its sudden occurrence during a febrile process; in being 
non-inflammatory ; in its vesicles not breaking down ; 
and in not itching. Lichen tropicus differs from eczema 
in the minuteness of its papules ; its sudden appearance ; 
not forming patches which are moist; having a high 
atmospheric temperature as an evident etiological factor, 
and the tingling rather than the itching of the eruption. 

Treatment. Sudamina needs no treatment, as with 
the subsidence of the fever it gets well of itself. Lichen 
tropicus requires attention to the diet, cutting off the meat 
in children and lessening its amount in adults. Cooling 
drinks and the administration of gentle saline laxatives 
are also advisable. Locally, bathing in salt water or 
alkaline lotions, and subsequent powdering of the skin, 
conjoined with wearing light clothing, and not using 
too warm bedcovers, will relieve and ofttimes cure the 
trouble. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. The 
epidemics have occurred most often in France. 

Milium. Synonyms : Grutum ; Strophulus albidus ; Acne 
albida ; Tuberculum sebaceum. 

Symptoms. These are small pinhead- to split-pea- 
sized, firm, whitish or yellowish, slightly elevated papules 
that occur usually upon the face. They are spherical in 
shape, and slowly increase in size up to a certain point, 
when they remain stationary. When incised and pressed 
upon laterally a small, white, round, oval, or lobulated 
mass emerges. They give rise to no subjective sensation. 
While their most common site is the face below the eyes, 
they may occur anywhere on the face ; and also upon 



384 DISEASES OF THE SKIN. 

the border of the lips, the penis, and scrotum. In this 
latter situation they are more decidedly yellow in color, 
flat, and often attain the size of a small bean. Along the 
corona glandis they are sometimes very thickly strewn. 
On the genitals of women their most frequent site is the 
labia minora. There may be but one or two, or a score of 
them. Occurring in the eyelids they are called chalazion. 
When they undergo calcareous degeneration (an infrequent 
occurrence) they form cutaneous calculi. Comedones are 
often present at the same time with milia. Any part of 
the body may be affected. 

Etiology. Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, 
such as pemphigus, erysipelas, or those in which destructive 
processes have taken place and cicatrices formed. They 
are often congenital. 

Pathology. They are supposed to be due to retained 
secretion on account of the upper layers of the stratum 
corneum growing over the openings of the sebaceous 
glands, or to a non-development of the glands. Robinson 
thinks that some of them are due to " miscarried embry- 
onic epithelium from a hair follicle or from the rete," 
while those " following pemphigus, erysipelas, syphilis, 
and lupus consist of fatty epithelium and cholesterine, the 
epithelium being often arranged in concentric layers around 
a central flat nucleus." 

Diagnosis. They must be differentiated from xan- 
thoma. The latter are more of a lemon-yellow or buff 
color, and cannot be squeezed out when incised. Mollus- 
cum is sometimes mistaken for milium, but it is more 
prominent and hemispherical, and has a central punctum, 
out of which its contents can be squeezed without punct- 
uring its top. 

Treatment. The treatment consists in pricking the 
top of the papule and pressing out its contents. To make 
sure of the destruction of the growth a drop of carbolic 
acid or iodine may be introduced into the cavity re- 
maining. Hardaway advocates electrolysis as being the 
speediest and best treatment. If operative procedures are 
inadmissible, the skin may be caused to exfoliate by the 



MOLL TJSCUM CONTA GIOS UM. 



385 



use of green soap or salicylic acid, when the milia will be 
destroyed. 

Milk Crust. See Eczema. 

Mitesser. See Comedo. 

Mole. See Nsevus. 

Molluscum Cholesterique. See Xanthoma. 

Molluscum Contagiosum. Synonyms : Molluscum epi- 
theliale, seu sebaceum, seu verrucosum, seu sessile ; Epi- 
thelioma contagiosum ; (Fr.) Acne varioliforme, Ecder- 
moptosis. 

Fig. 50. 




Molluscum. (After Allen.) 



Symptoms. This is a contagious disease of the skin 
that occurs in most cases upon the face and in children, 

25 



386 DISEASES OF THE SKIN. 

and is characterized by the appearance of one or more 
rounded pearly white or pinkish discrete tumors, varying 
in size from that of a pin head to that of a large pea. (Fig. 
50.) These tumors are waxy or opaque, and on top are 
slightly flattened, and show an umbilieation or small 
depression, out of which the soft cheesy contents of the 
tumors can be squeezed. These tumors are at first very 
small, but gradually grow until they attain a certain size, 
when they may remain unchanged for an indefinite period ; 
or they may become inflamed, break down of themselves, 
discharge their contents, and disappear either without leav- 
ing any trace or with a very slight scar. There are not 
infrequently scores of these tumors to be found on the 
same subject. They are commonly sessile, but may 
become more or less pedunculated. The genitalia, breast, 
and scalp are affected next to the face in point of fre- 
quency, while the tumors may occur anywhere but on the 
palms and soles. 

Etiology. Children are far more often aifected than 
adults. If adults are affected, it will usually be found 
that they are in attendance upon children who have mol- 
luscum. The bad hygienic conditions under which poor 
people live seem to predispose to the affection, as it is rare 
to meet with it among the well-to-do. There is little doubt 
that the disease is contagious. Though inoculation-experi- 
ments have failed in most instances, still there have been 
a few cases in which they were successful. In the 
spring of 1891 a child with molluscum contagiosum came 
into my service in Randall's Island Hospital, and within a 
few weeks, no attempt being made to destroy the tumors, 
there were six cases in the wards. 

Pathology. The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. 
One of the most characteristic features of the disease is 
the so-called " molluscum corpuscle," which is but a changed 
epithelial cell. (Fig. £1.) These appear, under the micro- 
set >pe, as large, ovoid, lustrous bodies, without nuclei, some 
being either wholly or partly contained in an epidermic 



MORBILLI. 387 

envelope, and some being entirely uncovered. Several 
parasites have been declared to be the cause of the disease 
by different investigators. 




Molluscum corpuscles. (After Kaposi.) 

Diagnosis. The appearance of the disease is so charac- 
teristic as to be diagnostic. It is most apt to be confused 
with milium ; but if it is remembered that a milium has 
no central depression, while a molluscum has, the confusion 
will exist no longer. If the lesions are taken for the vesico- 
pustules of variola, a scarcely probable occurrence, prick- 
ing their tops will at once show that they are not pustules, 
and if they are watched for a day or so it will be found 
that they remain unchanged. 

Treatment. The speediest way of getting rid of the 
tumors is to scrape them off with a curette. To insure 
their not returning it is advisable to touch the base of each 
tumor with a drop of carbolic or stronger acid. Or 
it is sufficient to make a small slit in the top of the tumor 
with a scalpel, squeeze out the contents, and touch the base 
with carbolic acid. 

Molluscum Epitheliale. See Molluscum contagiosum. 

Molluscum Fibrosum, seu Pendulum. See Fibroma. 

Molluscum Sebaceum, seu Verrucosum. See Molluscum 
contagiosum. 

Monilethrix. See Atrophia pilorum propria. 

Morbilli. Synonyms : Rubeola ; Measles. 

This is one of the contagious exanthemata. Its stage 



388 DISEASES OF THE SKIN. 

of incubation is from eight to twenty-one days, usually 
from ten to twelve days. It is characterized by prodro- 
mata of marked catarrhal symptoms, such as conjunctivitis, 
coryza, and bronchial inflammation, more or less fever, and 
constitutional disturbance; and then, on about the third 
day, an eruption of small, red, flat papules that rapidly 
enlarge, and uniting with others form mulberry-colored 
little patches often of a crescentic shape, with areas of 
sound skin between. H. Koplik 1 calls attention to the 
fact that one or two days before the eruption appears on 
the skin there will be found on the buccal mucous mem- 
brane and on the inside of the lips small, irregular, bright- 
red spots with a minute bluish speck in the center. The 
eruption begins on the face and neck, spreading downward, 
from which it covers the whole body in about a day and a 
half. The fever begins to decrease on the second day of 
the eruption. The rash begins to disappear by the third 
or fourth day, and is gone by the ninth day. Furfuraceous 
desquamation follows the subsidence of the exanthem. 
Sometimes it is so slight as to be hardly noticeable, and 
it is never so marked as in scarlatina. 

Diagnosis. The only dermatosis with which measles 
is apt to be confounded are an erythema, rubeola or Ger- 
man measles, variola, and the macular syphilide. But the 
catarrhal symptoms ; the regular progression of the erup- 
tion from above downward ; and the crescentic patchy 
arrangement and dark color of the lesions are sufficient to 
differentiate it. In erythema we may have some constitu- 
tional disturbance, but it is of short duration ; the eruption 
is more pronounced on the trunk and extremities, and 
shows no order of progression ; the color of the eruption 
is a brighter red ; there is an absence of crescentic arrange- 
ment ; and very often an accompanying urethritis will 
suggest the ingestion of some of the balsams as a cause 
of the trouble. In rubeola there is not so much constitu- 
tional disturbance, less catarrhal complications, and a pro- 
nounced swelling of the glands of the neck. The erup- 
tion is usually a remarkably fine papular one, not so 
patchy as in measles. Variola in its early stage is some- 
1 Arch. Pediat., Dec, 1896. 



MYCOSIS FBAMBCESIODES. 389 

times difficult to diagnose from measles. Backache is 
usually a marked symptom in variola ; its papules are 
smaller, harder, and more shot-like, and lack the crescen- 
tic arrangement of measles. The subsequent course of 
the disease is, of course, very different from that of measles. 
The erythematous syphilide affects the sides of the chest 
and the abdomen more than the face ; the rash lasts for 
weeks after any possible fever has passed ; its lesions have 
no definite arrangement and come out in successive crops, 
so that at the same time there will be present lesions of 
different age, and staining of the skin from those that 
have gone. 

Treatment is purely symptomatic. 

Morbus Elephas. See Elephantiasis. 

Morbus Maculosus Werlhofii. See Purpura. 

Morbus Pedicularis. See Pediculosis. 

Morphcea. See Scleroderma. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, 
bullae, and fissures of the palmar side of the hands and 
fingers, and paronychia and necrosis of several phalanges. 
It is allied to, if not identical with, syringomyelia, which 
see. 

Morve. See Equinia. 

Moth Patch. See Chloasma. 

Mother's Mark. See Nsevns. 

Multiple Fungoid Papillomatous Tumors. See Mycosis 
fungoi'des. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by certain kinds of flies, which lay 
their eggs under the skin. These subsequently hatch out 
and give rise to the dermatitis. 

Mycetoma. See Fungous foot of India. 

Mycosis Framboesiodes. See Dermatitis papillaris ca- 
pillitii. 



390 DISEASES OF THE SKIN. 

Mycosis Fungoides. Synonyms : Inflammatory fungoid 
neoplasm ; Multiple fungoid papillomatous tumors ; Fi- 
broma fungoides ; Lymphadenie cutanee ; Granuloma fun- 
goides ; Eczema hypertrophicum seu tuberosum ; Ulcer- 
ative scrofuloderma; Lymphodermia perniciosa; Sarcoma- 
tosis generalis ; Multiple sarcoma cutis ; Fungoid derma- 
titis ; Beerschwamahnliche multiple Papillargeschwiilste 
der Haut. 

A chronic progressive disease of the skin, characterized 
by the appearance with or without an antecedent erythe- 
matous or eczematous stage, of fungating tumors that tend 
to break down and ulcerate. It leads, through marasmus, 
to death. 

Symptoms. The many names that have been applied 
to this rare disease testify to the uncertainty of our knowl- 
edge of its proper place in the classification of skin dis- 
eases. It assumes so many forms that it is impossible in 
our limited space to give a complete picture of the disease. 
In some cases the first thing noticed is what appears to be 
a simple eczema, erythema, urticaria, or psoriasis in vari- 
ously sized patches, tending to be round or circinate in 
form, and accompanied by marked pruritus. These lesions 
occur anywhere, and constitute the first stage of the dis- 
ease. They may disappear for a time, to reappear in the 
same places or elsewhere. After some months, or two or 
three years or more, the patches become raised, glistening, 
and infiltrated, more deeply red, and pea-sized papules 
form. These disappear, and new ones form. This is the 
second stage, and may last months or years. Then the 
characteristic tumors form either by the papules enlarging 
and coalescing, or as tumors at once rising out of the 
sound skin, without antecedent erythematous stage. The 
tumors are oval, hemispherical, annular or irregular in 
shape, sharply defined, sometimes slightly pedunculated. 
They are of* whitish, bright-red, bluish-red, or dark-red 
color. They are sometimes hard and clastic, sometimes soft 
and succulent. The epidermis over them is tense, thin, and 
glistening. They may be absorbed and disappear, new 
ones appearing ; or they may become necrotic and ulcerate. 
In size they vary from that of a pea to that of the fist. 



MYCOSIS FUNGOIDES. 391 

At first they occur only on the trunk; later they oome 
anywhere, and involve even the mucous membrane of the 
mouth. The itching and pain continue well into the 
tumor-stage, when they lessen. The lymphatic glands 
enlarge painlessly. The hair falls from over the tumors. 
The general health of the patient is undisturbed for a long 
time, but at last a general marasmus sets in and the patient 
dies, usually from an uncontrollable diarrhoea or some com- 
plication on the side of the lungs. There has been but 
one case of recovery reported. 

Etiology. The majority of the cases have been in 
men over forty years old. The disease is held not to be 
contagious by some, while others hold the opposite opinion. 
Blanc l found in one case that there was a marked reduc- 
tion in the white blood corpuscles, their proportion to the 
red being 1 to 130, instead of 1 to 350 or 500. This is about 
all that is known of the etiology of the disease. While 
much study has been given to the pathology of the affec- 
tion there is no agreement among pathologists as to its 
essential nature. By many it is supposed to belong to the 
class of infecting granuloma. 

Diagnosis. The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot 
be made with certainty. There is something peculiar in 
the sharply circumscribed outline, the chronicity, circinate 
form, and capriciousness of the patches. Psoriasis affects 
other localities at first, its patches are not so infiltrated, 
and it is more scaly. Eczema is a moist disease at some 
time and more multiform in character. When the tumors 
develop, and the capricious manner of their coming and 
going is observed, the diagnosis is more evident. 

Treatment. Thus far nothing has been found to stay 
the course of the disease, except that Kobner reports the 
cure of a case by means of hypodermic injections of arsenic. 
A general tonic treatment is always indicated. Locally, 
pyrogallol ; ichthyol ; mercurial ointment ; injections of 
carbolic acid ; resorcin, and camphorated naphtol have 
been used, and may be tried. The itching is most rebel- 
lious to treatment. The tumors, when not in great num- 
1 Joiirn. Cutan. and Gen.-Urin. Dis., 1888, vi., 256. 



392 DISEASES OE THE SKIN. 

bers, may be cut out, though the operation is of doubtful 
utility. The ulcerations that result from breaking down 
of the tumors must be treated on surgical principles. 

Prognosis. Death is the outcome of the disease, and it 
may occur in from a few months to fifteen years, the aver- 
age being from two to four years. 

Mycosis Microsporina. See Chromophytosis. 

Myoma. Like most of the tumors, so this one concerns 
the surgeon more than the dermatologist. Two main 
varieties are described, namely, simple or liomyoma and 
dartoic. Myomata may be single or multiple. They are 
composed of muscular fibers, and vary in size from that of 
a split pea to that of an orange. They are painful on 
pressure, and sometimes spontaneously. They are pink, 
red, or normal in color, disseminated or aggregated into 
patches, though still retaining their individuality. The 
epidermis over them is unchanged. The single tumors 
may be sessile or pedunculated, and may attain the size of 
an orange. The dartoic variety has its seat most often on 
the female breasts, and on the genitalia of both sexes, and 
is usually a single tumor. Simple myoma are more com- 
monly multiple, and occur upon the upper extremities, 
though they may occur anywhere on the body. Most of 
the cases are in middle-aged or elderly men. If they con- 
tain a good deal of fibrous tissue, they are called fibro- 
myoma ; if they contain large blood vessels, they form 
anr/io-myoma ; or, if the lymphatics are involved, we have 
lymphangio-myoma. The diagnosis is often difficult with- 
out the aid of the microscope. Excision is the only thing 
that can be done for them. 

Myoma Telangiectodes. See Myoma (Angio-myoma). 

Myxadenitis Labialis. See Cheilitis glandularis. 

Myxoedema. This is a constitutional disease with cu- 
taneous symptoms. The skin becomes waxy pale ; yellow- 
ish ; shining in some places, dull and earthy-looking in 
others ; it is dry, scaly, exfoliating on the extremities 
sometimes ulcerated, and verrucose on the lower limbs. 
Tho fingers and toes are sometimes livid. There are 



NJSVUS PIGMENTOSUS. 393 

partial or general alopecia, and deformity and fragility 
of the nails. There is a general (edematous swelling 
of the whole integument as well as of the mucous mem- 
branes, and this oedema does not pit on pressure. The 
swelling is most marked in the face. The skin about the 
eyes becomes puffed up so as almost to close the eyes. 
Cushions of fat fill the supraclavicular spaces. There is 
atrophy of the thyroid gland. The patient's intellectual 
faculties become dulled, the speech is slow, and the gait 
unsteady. 

The disease affects women far more often than men, and 
involves all parts of the body. There are an enfeeblement 
of mind, and a great impairment of the senses of touch, 
taste, and smell ; a torpidity of movement and of the 
digestive functions. It ends fatally either by marasmus 
or by complications on the side of the internal organs. 

The diagnosis in the early stage is difficult ; when fully 
developed it could hardly be taken for anything else. The 
cause of the disease is unknown. 

Treatment. All the symptoms are removed by the 
use of thyroid extract or powder, improvement being 
rapid. When the treatment is stopped the patients after 
a time lapse into their former state, so that the adminis- 
tration of the thyroid has to be more or less continuous. 

Nsevus. A nasvus, strictly speaking, is a congenital 
mark or growth in the skin, which may be either pigmen- 
tary or vascular. The name is occasionally applied to 
acquired new growths similar to the congenital ones. 

Nsevus Araneus. See Telangiectasis. 

Nsevus Lupus. See Angioma serpiginosum. 

Nsevus Pigmentosus. Synonyms : Nasvus spilus ; Nasvus 
pilosus ; Nasvus verrucosus ; Nasvus lipomatodes ; (Ger.) 
Fleckenmal, Pigmentmal, Linsenmal ; Pigmentary mole ; 
Mother's mark. 

A congenital, circumscribed hyper-pigmentation of the 
skin, often accompanied by a growth of coarse hair and 
hypertrophy of the connective and fatty tissues. 

Symptoms. These growths are closely allied to lentigo 



394 



DISEASES OF THE SKIN. 



and chloasma, as a hypertrophy of pigment is a promi- 
nent feature of them. When they consist of pigment 
onlv, and are not raised above the surface of the skin, 
they are called ncevus spilus. When besides the pigment 
there is an hypertrophy of the connective tissue, and they 
are raised and uneven, the name ncevus verrucosus is ap- 
plied to them ; or ncevus lipomatodes if they are soft and 
contain fatty tissue ; if hair grows from either form, then 
we speak of ncevus pilosus. In color they vary from a light 

Fig. 52. 




Naevus lipomatodes. 



to dark brown or black. In size they vary from that of a 
split pea to that of an area large enough to cover the whole 
back. Most commonly they are of small size. They may 
be located anywhere, though most often on the face, neck, 
and back. There may be but one or two, or hundreds of 
them. They may have no special distribution, or they 
may occur in streaks or bands. They may be unilateral 
or bilateral, and sometimes symmetrical. If hair is in 
them, it is coarse and stiff, and generally darker than that 



NJEVUS PIGMENTOSUS. 395 

of the head. Sometimes large hairy moles bear a strong 
resemblance to the fur of animals. They grow in pro- 
portion to the growth of the individual, and cease grow- 
ing when he has attained his growth. They are usually 
congenital, but may be acquired, and are liable to undergo 
malignant change in advanced life. They give rise to 
no subjective symptoms. They are permanent growths. 
They rarely disappear of themselves. 

Etiology. To account for the appearance of these 
malformations we have only the theory of nerve-influence, 
and that is by no means satisfactory. Their popular name 
of mother's mark shows that the popular superstition 
agrees with the scientific theory. We can simply regard 
them as anomalies. 

Diagnosis. Moles differ from lentigo in being con- 
genital and permanent, and in a hypertrophy of connec- 
tive tissue and a growth of hair being connected with 
them. The difference between hairy moles and hyper- 
trichosis is in the substratum ; in the latter the underlying 
skin is otherwise normal. 

Treatment. We can destroy these growths and leave 
behind but little scar. If there is but a single pigmen- 
tary mole, it may be cut out. In this case it will leave a 
linear scar. It is generally better to destroy the growth 
by touching it over carefully with nitric or glacial acetic 
acid. This is done by stippling, as it were, making a row 
of dots in this fashion — 



Electrolysis by multiple puncture, or by transfixing the 
mole in various directions, is a sure and speedy way. J. 
Brault 1 recommends tattooing them with a solution of 
thirty parts of chloride of zinc and forty parts of sterilized 
water. The eschar falls in five to ten days. It may be 
necessary to repeat the process. Hairy moles are best 
destroyed by electrolysis, as in superfluous hair, only here 
a coarser needle may be used, as we are not so particular 
1 Ann. de derm, et de syph., 1895, vi., 33. 



396 DISEASES OF THE SKTN. 

about a little scarring. The warty growths may be re- 
moved by a curette. 

Naevus Unius Lateris. See Papilloma lineare. 

Nsevus Vascularis. Synonyms : Nsevus vasculosus seu 
sanguineus ; Angioma (Ger.) Feuermal, Gefassmal ; (Fr.) 
Tache de feu, Tache vasculaire ; Port-wine mark ; Birth- 
mark ; Claret stain. 

Symptoms. These are composed mainly of vascular 
tissue, and are congenital or appear during the first month 
of life. They are usually single, but may be multiple. 
They vary greatly in size, shape, and color, but all possess 
one feature in common — they pale under pressure. They 
may be pinhead-sized spots not raised above the surface of 
the skin ; or they may form large, erectile, elevated, pulsat- 
ing tumors ; or they may spread out so as to involve a 
large area. They may be pink, bright red, dark red, or 
even purple in color. When on the face they become more 
pronounced on crying, coughing, and the like. They 
may disappear spontaneously ; increase in size during 
a few months or years ; or, most commonly, remain un- 
changed. According to their size they have received 
various names. The small, flat, or scarcely raised nsevus 
composed of capillaries is called ncevus simplex, or capil- 
lary nsevus. This is the form very often seen in children. 
It is not infrequent for it to disappear of itself after a 
while, leaving either no trace or a delicate atrophic scar. 
When it is so large as to form a patch as big as the hand 
or larger, it is called ncevus JJammeus, or port-wine marl;. 
The surface of this form is often uneven and studded 
with small erectile vascular tumors, or, may be, pigmen- 
tary moles. It often becomes dark purple after exposure 
to cold. The large erectile pulsating tumors are called 
ncevus tuberosus, angioma cavernosum, venous ncevus. They 
differ very much from the other forms in appearance and 
formation. Their surface is uneven and lobulated. This 
form is apt to increase in size, and may attain enormous 
dimensions. 

Nsevi may occur anywhere on the body, but are most 
frequent on the head and face. They may also occur 



NMVUS VASCULARIS. 397 

upon the mucous membranes primarily or secondarily. 
The back, nates, pudenda, and lower limbs are said by 
Crocker to be the most common sites of the cavernous 
form. All forms of naevi may be hardly perceptible at 
birth, but become gradually more evident afterward. 

Etiology and Pathology. Vascular nsevi are prob- 
ably always congenital malformations, though their ap- 
pearance upon the skin may be retarded for some time. 
The simple capillary nsevi, which include the port-wine 
marks, are simply an increase in number and size of the 
capillaries. In the venous nsevi we have also a new 
growth of connective tissue forming a meshwork, and they 
are supplied directly by an artery without the interposi- 
tion of capillaries. Women are more prone to naevi than 
are men. 

Diagnosis. There can be no difficulty in diagnosis, 
excepting that a nsevus may be taken for a telangiectasis. 
This error would be of little consequence, since the latter 
is simply an acquired nsevus, and differs chiefly in having 
a central red point from which the dilated capillaries 
radiate. 

Teeatment. Electrolysis is the best means for de- 
stroying the vast majority of these growths. The current 
strength should be from two to three milliamperes. The 
best way to use it in capillary nsevi and port-wine marks 
is by making multiple punctures in parallel rows, perpen- 
dicularly to the skin and down through its entire thick- 
ness. To expedite matters, one may use either a circle of 
needles set in a handle or a row of three needles. The 
negative pole is to be connected with the needle-holder, 
and the operation is to be conducted in the same way as in 
removing superfluous hair. By this method it is possible 
to destroy small nsevi entirely, and to diminish very much 
the unsightly appearance of large port-wine marks. As 
electrolysis necessarily destroys the skin, we must leave a 
scar. But this is less conspicuous than the nsevus, and if 
the operation is carefully done the scar is soft, smooth, 
and pliable. There is also much less danger of a deform- 
ing scar from the use of a single needle than from a 
group of them. Therefore this method is preferable, 



398 DISEASES OF THE SKIN. 

though more tedious. The punctures must not be made 
close together ; at least a sixteenth of an inch should he 
left between them. After the naevus has been carefully 
gone over, it should be left alone for a couple of weeks or 
more for the full effect of the operation to be seen. It 
can be gone over again, and another interval of time al- 
lowed, and so on till the growth is destroyed as much as 
possible. 

Besides electrolysis we may use multiple scarifications 
obliquely to the skin. Or we may use the ethylate of 
sodium freshly prepared and applied to the absolutely dry 
skin, using a brush or glass rod. To avoid scarring, only 
a small part of the noevus must be attacked at a time. 
A crust will form, which must be left to come away of 
itself. Fuming nitric acid or the acid nitrate of mercury 
may be stippled over the growth. Or vaccination may 
be performed over it. Or multiple punctures may be 
made by means of a steel needle dipped in nitric or car- 
bolic acid. Marshall Hall advocates breaking up the 
nsevus by introducing a cataract-needle close to the edge 
of the growth, pushing it across to the opposite side, then 
nearly withdrawing it, and again pushing it in at a little 
distance from the first puncture. But electrolysis is the 
best and most controllable method. 

For cavernous naevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the hope 
of striking the deep vessels. It is well, sometimes, to pass 
the needle from the edge deep under the nrevus and clear 
through to the other side, let the current pass for half a 
minute, partially withdraw the needle, and again push it 
in another direction. Some prefer introducing two needles, 
connected each with one pole of the battery, in opposite 
directions. A platinum or gold needle must be used with 
the positive pole. A current strength up to five milliam- 
peres is often necessary to destroy these growths. Excision 
may be performed, but sometimes this gives rise to alarm- 
ing hemorrhage. Multiple punctures with a steel shoe- 
maker's awl, heated to a red heat and allowed to cool to a 
Mack heat, or the point of a Paquelin or galvano-cautery 
heated to a dull red, are other good methods of treatment. 



NODOSITAS CRINIUM. 399 

It has been proposed to use a metallic plate perforated 
with a number of holes with which to exercise strong 
pressure upon the nsevus while the galvano-cautery is in- 
troduced through the holes. Injections of carbolic acid, 
perchloride of iron, alcohol, and the like, are effectual 
but dangerous methods. Setons are not used as much as 
formerly. Compression by an elastic bandage is at times 
curative when the nsevi are located over bony prominences. 

As many capillary nsevi in children disappear in time, 
it is advisable not to interfere with them at once, content- 
ing ourselves with painting them with collodion and wait- 
ing until the child is old enough to desire their removal. 
Unna thinks that the addition of ten per cent, of ichthyol 
to the collodion increases its efficacy. Of course, if they 
are very unsightly we cannot wait, nor should we tempor- 
ize with cavernous nsevi. In children one works most 
comfortably by using an ansesthetic, but it is not absolutely 
necessary. Keloidal scars may be an unfortunate result 
of treatment in some cases. 

Prognosis. The prognosis should be guarded, and the 
cases carefully watched. All nsevi may increase in size, 
though very many remain stationary. 

Naevus Verrucosus. See Papilloma lineare. 

Narbengeschwulst. See Keloid. 

Nerven Naevi. See Papilloma lineare. 

Nesselausschlag. See Urticaria. 

Nettlerash. See Urticaria. 

Neuralgia Cutis. See Dermatalgia. 

Neuroma Cutis is an exceedingly rare disease, of which 
but few cases have been reported. Neuromata are small, 
flat, pinkish or pale-red firm tumors firmly imbedded in 
the skin. They are painful spontaneously and on press- 
ure. The pain may be paroxysmal in character. They 
are relievable by surgical interference with the nerve. 

Neuropathic Papilloma. See Papilloma lineare. 

Nodositas Crinium. See Trichorrhexis nodosa. 



400 DISEASES OF THE SKIN. 

Nodositas Pilorum Microphytica. See Tinea nodosa. 

Nodosit6s Non-erythemateuses des Arthritiques. Brocq 
applies this name to cutaneous and subcutaneous tumors 
that lie has met with in connection with the gouty diath- 
esis. They are of two varieties. The first one he calls 
ephemeral cutaneous nodules. They occur upon the fore- 
head and form ill-defined elevations of the skin, of small- 
pea to hazelnut size, and entirely painless. They are 
movable with the skin, though sometimes they are adher- 
ent. They appear first during the night and disappear 
within twenty-tour hours. 

The second variety is the .subcutaneous rheumatismal 
nodule. It forms a small tumor resembling a gumma. 
The skin slides freely over it in most cases. The color of 
the skin is unchanged. It is firm and elastic to the touch. 
Generally such tumors are painful on pressure, at times 
spontaneously. In size they vary from that of a pea to 
that of an almond, and they are sharply defined. They 
may remain for days or weeks, when they disappear, leav- 
ing no trace. They often come in successive outbreaks. 
Their seat of predilection is about the joints, and upon the 
fibrous tissues that cover the superficial bones. They are 
generally discrete, and frequently very numerous. Their 
appearance often coincides with symptoms of pericarditis 
or pleurisy. Their treatment is that appropriate to the 
rheumatism that seems to be their cause, especially iodine 
and the iodides. 

Nodulus Laqueatus is that condition of the hair in 
which it seems to tie itself into knots. The hair is usually 
dry and curly. It is probably caused by handling of the 
hair, and does not occur spontaneously. 

Noli me Tangere. See Lupus vulgaris. It has been 
used as a synonym for rodent ulcer. (Crocker.) 

(Edema Cutis, Acute Circumscribed. This disease is also 
called avc/io-neurotic oedema, acute idiopathic cedema, peri- 
odic or giant swelling. It is a question whether this is a 
form of urticaria or not. It is certainly allied to it in the 
suddenness of its onset ; in the attending erythema and 



(EDEMA NEONATORUM. 401 

digestive or other constitutional disturbances ; and in the 
character of its lesions. It differs from urticaria in being 
recurrent in the same locations ; in the shading oif of the 
swellings into the surrounding skin ; and in being unat- 
tended by itching. It is prone to occur upon the face, 
and there often closes one or both eyes in an enormous 
swelling ; or the lips so that the mouth cannot be opened. 
In some cases a history may be obtained of the occurrence 
of the same disease in other members of the family. It 
usually begins in early adult life and tends to recur. It 
may occur on the mucous membranes, causing suffocative 
attacks if the larynx is involved, and acute digestive dis- 
turbances if the stomach is affected. It occurs in various 
parts of the body as dull-red swellings that appear sud- 
denly and disappear in a few hours. While these do not 
itch, the patient complains of burning, tension, and throb- 
bing. In the present state of our knowledge it is proba- 
bly well to regard it as urticaria oedematosa. The treat- 
ment is the same as in urticaria. (See Urticaria.) 

(Edema Neonatorum. This disease was formerly con- 
founded with sclerema, but is now separated from it. 

Symptoms. It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema 
spreads upward along the thighs, shows itself upon the 
hands, then upon the genitals and back. It is hard, and 
pits only on deep pressure. The skin is of a violaceous 
red or more or less intense yellow, and feels cold. The 
infant is comatose; its pulse is feeble; its breathing 
labored; and its cry sharp. A high temperature may 
exceptionally be present. Death usually results on ac- 
count of some pulmonary affection, or from collapse. Ex- 
ceptionally, recovery takes place. 

Etiology. The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered or exposed to 
poor hygienic surroundings. 

Diagnosis. It differs from sclerema in being more 
limited to certain localities; in the skin being more livid 
from the first, and not .so hard ; in affecting the dependent 
parts; and in lacking the stiffness of the joints. (Crocker.) 



402 DISEASES OF THE SKIN. 

Treatment. Though the prognosis is exceedingly 
bad, an attempt should be made to nourish the child as 
well as possible by artificial feeding ; it should be wrapped 
in flannel and kept warm ; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 

(Eil de Perdrix. A soft corn. 
Oligotrichia. See Alopecia. 
Onychatrophia. See Atrophia unguium. 

Onychauxis, Onychogryphosis. These are both hyper- 
trophies of the nail, either in length, breadth, or thick- 
ness ; or in all at the same time. When the growth is 
markedly forward and the nail is much thickened, it is 
called onychogryphosis. The nail in these instances gen- 
erally turns to one side after reaching a certain length, 
sometimes so much so that a big-toe-nail may lie over the 
second and third toes. If the hypertrophy is lateral, we 
are apt to have onychia — ingrowing toe-nail. The hyper- 
trophied nail is rugous, but highly polished, brown, and 
there is often an accumulation of scales under it, which at 
times gives rise to a bad odor from decomposition. The 
toe-nails are those most often hypertrophied, but the finger- 
nails may be so affected. 

Etiology. Badly fitting boots and neglect of proper 
care of the nails are causes of onychauxis and onycho- 
gryphosis. They often arise without discoverable cause. 
They may be due to a congenital predisposition. They 
very often occur as part of some chronic skin or constitu- 
tional disease, such as eczema, psoriasis, leprosy, syphilis, 
and ichthyosis. The thickening may be due to disease of 
the matrix or to a thickening of the horny layer only. 

Treatment. The hypertrophied nail may be removed 
by mechanical means, such as by a file, saw, or knife. 
The continued use of salicylic acid sometimes will cause 
the thickened mass to fall off. The oleates of tin and 
lead ; the continuous wearing of rubber cots ; and licpior 
potassse, are also efficacious in softening the thickened 
mass of the nail. The action of all these agents is as- 



ONYCHIA. 403 

sisted by daily removing the softened layers by mechan- 
ical means. When the hypertrophy is but a part of some 
other disease it will be benefited by the same means as 
will benefit the cause from which it arises. If it is due 
to an inflammatory disease of the nail-bed or matrix, that 
must receive attention. (See Onychia and Paronychia.) 
After the nail-deformity has been overcome it may return. 

Onychia or Onychitis. By this is meant acute inflamma- 
tion of the matrix and nail-bed. The end of the finger 
or toe is reddened and swollen, and there is more or less 
throbbing pain. The nail is lifted from its bed, more or 
less pus escapes from underneath it, and it is eventually 
shed. The inflammation often spreads to the adjacent 
parts of the finger, and then we have that condition com- 
monly called whitlow. When the nail falls a spongy 
nail-bed is left, often with exuberant granulations. Under 
proper treatment a good nail may be reproduced, though 
in many cases either a very much deformed one will result 
or one that differs somewhat in appearance from the other 
nails. In some cases, instead of this phlegmonous form, 
we have a dry inflammation that is known as onychia sicca. 
Here the nail is discolored, its edge thickened and brittle, 
its surface rough and more or less pitted. Eventually the 
nail is shed. This condition is met with most often in 
syphilis. A chronic onychia is occasionally seen, and is 
one of the causes of onychauxis. 

Etiology. Onychia is due to traumatism or to some 
other disease of the skin, such as syphilis, eczema, psoria- 
sis, parasitic diseases, dermatitis exfoliativa, rheumatism, 
and the strumous state. 

Treatment. The treatment of onychia varies with 
the stage of the disease and with the cause. Occurring as 
part of some general disease of the skin, the treatment ap- 
propriate to the general disease will be beneficial to the 
onychia. Arising as an independent disease, or resulting 
from traumatism, the application of a ten to twenty per 
cent, resorcin ointment or plaster, or painting with tincture 
of iodin, will often abort the disease in an early stage. If 
the disease has gone on to suppuration, surgical procedures 



404 DISEASES OF THE SKIN. 

will have to be resorted to, such as splitting of the nail or 
its removal as a whole, and subsequent dressing with iodo- 
form, aristol, or a bichloride solution. 

Onychomycosis. This term means the invasion of the 
nail by a fungus, such as the trichophyton or achorion. 
For further information see Trichophytosis and Favus. 

Osmidrosis. See Bromidrosis. 

Osteosis Cutis. A case of osteosis of the skin of the foot 
was reported by Sherwell 1 in 1892. It involved the 
plantar surface of the left foot about the heel and on the 
fourth toe. The patches were of cartilaginous hardness, 
with horny surfaces studded with nodosities. The patches 
were fairly movable over the underlying parts. They 
were painful when stepped on. The patient was a girl six 
years old. The patches were excised, but formed again 
within six months. A histological examination by Cole- 
man 2 showed that they contained cancellous bone. 

Pachydermatocele. See Dermatolysis. 

Pachydermia. See Elephantiasis. 

Paget's Disease of the Nipple. Synonyms : Mamillaris 
maligna; Malignant papillary dermatitis; Epitheliomatose 
eczematoide de la mamelle (Besnier). 

Symptoms. This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 3 

It usually occurs in women over forty years of age, and 
at first has the appearance of an eczema madidans — that 
is, it presents " a florid, intensely red, raw surface, very 
finely granular, as if the whole thickness of the epidermis 
had been removed. From such a surface, on the whole or 
greater part of the nipple and areola, there is always a 
copious, clear, yellowish, viscid exudation." Besnier be- 
lieves that its primary stage is a keratosis, which, under 
any irritation, assumes an eczematous appearance. The 
edge of the patch is sharply defined and slightly raised. 
Sometimes, instead of the raw surface, we have crusting, 

1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 119. 

2 Ibid., 1894, xii., 18-5. 

3 St. Bartholomew's Hospital Reports, vol. x., p. 83. 



PAGET 'S DISEASE OF THE NIPPLE. 405 

or even scaling. Telangiectases may be seen here and 
there. After months or years marked induration is mani- 
fest, pinching up the patch imparting the sensation, as 
described by Mr. Morris, of "a penny felt through a 
cloth." Burning or itching is complained of, which makes 
the disease the more nearly resemble an eczema. But it 
does not yield to the ordinary treatment of eczema, and its 
border gradually extends. The female breast, usually the 
right one, 1 is the most often affected, and there it always 
begins at the nipple, spreading thence over the areola and 
skin. After a few months, or not until twenty years, signs 
of scirrhous cancer appear. The nipple becomes more and 
more retracted and ulcerated. Shooting pains are com- 
plained of. Hard nodules develop in the raw surface or 
deep down in the skin. The mammary gland itself may 
become affected. The disease in most cases is unilateral. 
The cancerous cachexia develops later with ganglionic en- 
largements. Crocker and Pick have met with it on the 
scrotum and penis, and one case has been reported of in- 
volvement of the nipple of a man. 

Pathology. It is still an open question whether the 
disease is malignant from the start, or, beginning as a 
simple inflammation, becomes malignant, just as we find 
epithelioma of the tongue developing upon a leucoplakia. 
Later investigations seem to indicate that the process is 
epitheliomatous from the beginning. J. A. Fordyce's 2 
investigations show the disease to be "an inflammation of 
the papillary region of the derma leading to oedema and 
vacuolation of the constituent cells of the epidermis, fol- 
lowed by their complete destruction in some places and 
abnormal proliferation in others." The changes in the 
lactiferous ducts are secondary. 

Diagnosis. Though very important, it is exceedingly 
difficult at first to differentiate positively a case of Paget's 
disease from an eczema. JEczema of the nipple is very 
common during the childbearing period, while Paget's 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating 

1 Wickham : Maladie de Paget. Paris, 1890. 

2 New York Med. Journ., 1897, lxvi., 445. 



406 DISEASES OF THE SKIN. 

surface of Paget' s disease, while we do have more varia- 
tion in the course of the disease, exacerbations, and seasons 
of apparent quiescence. In eczema the patch is not so 
sharply defined, and its border is not raised ; about it there 
are apt to be outlying pustules or vesicles, and there is 
not the papyrus-like induration. When the nipple be- 
comes retracted and ulcerations take place, together with 
shooting-pains and enlarged lymphatics, the diagnosis is 
easy. 

Treatment. At the beginning, and while the diag- 
nosis is still doubtful, the usual remedies for eczema should 
be tried. If these fail, as they will if the disease is not 
eczema, or if the right diagnosis is arrived at, powerful 
caustics must be used, if the disease is still superficial. We 
may use, as recommended by Darier, a solution of chloride 
of zinc, one in three, to produce an exfoliation of the dis- 
eased epidermis, and follow it with a mercurial plaster, 
alternating with iodoform or aristol. Or a chloride of 
zinc paste may be kept on, spread thickly on lint, for four 
to six hours, and the slough poulticed off or allowed to 
separate under wet boric lint, under oiled silk, as recom- 
mended by Crocker. 

The paste used in the Middlesex Hospital in these cases 
is made as follows : 

R Zinci chlorid., 

Liq. opii sed., 

Amyli, 

Aqua?, Sj; 32 M. 

S. Ft. pasta. 

When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed anti- 
septically. When nodules have formed and there is 
marked induration under an ulcerated surface, the whole 
diseased surface must be freely excised or the breast re- 
moved entire. In fact, it seems to me best to amputate 
the breast as soon as the diagnosis is made, when the 
patient is past the childbearing period. If an operation 
or the use of caustics is inadvisable for any reason, relief 
to the pain and discomfort may be had by dressing with a 
fuchsine solution one per cent, strength. 



3»v; 


16 


#v; 


16 


3iss; 


6 


5J; 


32 



PAPILLOMA LINEABE. 407 

Panaris Nerveux of Quinquaud belongs to that group 
of obscure diseases in which stand Morvan's disease and 
syringomyelia. It is characterized by swelling of the 
extremities, slight redness, and attacks of intense pain, 
terminating in eight to fifteen days by fissure of the finger- 
end and fall of the nail. Sometimes the skin of the finger- 
end becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant applica- 
tion of chloroform liniment, and of irritant lotions or 
frictions to the cervical region and along the course of the 
nerves supplying the parts. Internally, he advises the 
valerianate of ammonia or of quinine. 

Panaritium. See Paronychia. 

Panne hepaticuie. See Chloasma. 

Papilloma. By this term is meant a papillary out- 
growth from the skin. Such are common warts, verrucous 
eczema, papillary excrescences following ulceration, Kap- 
osi's dermatitis papillaris capillitii, ichthyosis hystrix, nsevus 
unius lateris, and the like. The term is, therefore, of 
uncertain significance. Some authors have described papil- 
lomata apart from the above-designated diseases, and Hard- 
away reports at length a case of general idiopathic papil- 
loma in a seven-months-old child. Mental defects have 
been noted in some of these cases. A muco-purulent 
secretion often is present, welling up between the papillae. 
The condition is a rare one. Under the name of ■papilloma 
area elevatum Beigel has described one of these rare cases. 

Papilloma Lineare. Called also papilloma neuroticum, 
ichthyosis hystrix, nerve ncevus, ncevus unius lateris. This 
is commonly described under ichthyosis. As it has no 
symptom in common with that disease, it is best to regard 
it as a separate disease. It occurs in the form of warty, 
papillary growths that may be isolated though grouped, 
and of pinhead size ; or, they may be massed together into 
elevated, dark-green plates traversed by deep lines ; or 
arranged in long lines of parallel rows. These growths 
may occur on only one side, and in a single region ; or on 
both sides of the body and in several regions. They some- 



408 



DISEASES OF THE SKIN. 



times seem to follow the course of nerves in their distribu- 
tion. While often congenital, they sometimes do not 
develop until a number of years after birth, and all tend 
to increase until early adult life. The peculiar arrange- 

Fig. 53. 




Papilloma lincarc. (Fox'.) 



ment of the lesions distinguishes the disease from ordinary 
warts. 

The treatment consists in scraping away the growths 
with a curette ; or applying a ten or twenty per cent, oint- 
ment or plaster of salicylic acid. 

Parakeratosis. Two forms of parakeratosis have been 
1 G. H. Fox : The Skin Diseases of Children. N. Y., 1897. 



PARASITIC DISEASES. 409 

described, namely, Parakeratosis scutularis 1 and Parakera- 
tosis variegata. 2 

Parakeratosis Scutularis. This case was that of a man 
forty-one years old. It occurred on the scalp, the whole 
of which, with the exception of a strip at the periphery, 
was covered by a thick, greasy crust that enveloped the 
hair in bundles. Some single hairs had on them cuffs of 
yellowish-white, waxy, horny substance, one inch or more 
long, that were in connection with the crusts on the scalp. 
The growth of the hair was not much interfered with. At 
the edge of the scalp was a hairless, red, dry, and rough 
strip. 

Parakeratosis Variegata. Of this form, two cases are 
reported. Both were men. The eruption appeared on 
the thighs, chest, and neck, and later involved nearly the 
whole body, except the head, palms, and soles. The color 
of the eruption was red, forming an irregular network with 
small sunken patches of normal skin. It was scaly and 
the skin was infiltrated. 

Parasitic Diseases. The diseases of the skin caused 
by parasites may be divided into two classes : 1 . Those 
due to vegetable parasites. 2. Those due to animal para- 
sites. 

Group 1 comprises favus, ringworm, chromophytosis, 
erythrasma, and pinta. These will be found described 
under their proper headings. In 1899 E. Lusk 3 reported 
a case whose symptoms resembled those of scabies, but it 
was due to mucor corymbifer that was found escaping 
from the vesicles. 

Group 2 comprises a large variety of parasites. Scabies 
and pediculosis, due respectively to the acarns and pedicu- 
lus, are described at length in this book. Besides these we 
have — 

The leptus autumnalis, harvest-bug, or mower's mite, 
that bores its head into the skin, causes great itching, and 
induces violent scratching and consequent excoriations. 

1 Internat. Atlas of Eare Skin Diseases, No. 3. 

2 Monatshefte f. prakt. Dermat., 1890, x., 404. 

3 Med. Eec, 1899, lvi., 204. 



410 DISEASES OF THE SKIN. 

The demodex folliculorum is described in relation with 
the comedo. 

The pulex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up 
inflammation and, perhaps, ulceration and gangrene, and 
has to be dug out of the skin with a blunt needle. 

The pulex irritans, or common flea, whose ravages are 
so well known as not to require description. 

The chnex leetularius, or common bedbug, attacks the 
skin for its food, punctures it, and at the same time injects 
an irritating fluid to increase the hyperemia and the food 
supply. A wheal, or raised red spot with a central punct- 
ure, follows the bite, and a purpuric spot results. The 
irritation is relieved by any of the means serviceable in 
urticaria. 

Gnats and mosquitoes and their effects are too familiar 
to all of us to require extended notice. 

Ixodes, or wood-ticks, the filaria sanguinis and filaria 
medinensis, the kenia solium, and the echinococcus, all find 
lodgement at times in the human skin. These parasites do 
not exhaust the list, but are the principal ones. 

Parchment Skin. See Atrophia cutis. 

Paronychia. This affection is popularly known as a 
whitlow, run-around, or ingrowing toe-nail. Ingrowing 
toe-nail results from the nail shoving or being shoved into 
the soft parts, either on account of disease of the nail itself, 
or of ill-fitting shoes, or of injury. The big toe-nail, at its 
inner or outer edge, is the most common site of the disease, 
though any toe may be affected, and even the finger may 
suffer. The furrow, fold, and bed of the nail all become 
inflamed, ulcerated, and exquisitely tender, discharging 
more or less pus. It is said to be more common in young 
people than in old, and far more frequent in men than in 
women. Paronychia of either the ulcerative or non-ulcer- 
ative form is frequently met with in syphilis. 

Treatment. Severe cases of paronychia most often 
find their way to the surgeon's hands. In syphilitic par- 
onychia general antisyphilitic treatment is required. In 
the non-ulcerative form mercurial ointment, diluted with 



PEDICULOSIS. 411 

one or two parts of diachylon ointment, may be used, or 
the mercurial plaster. In the ulcerative form the parts 
should be cauterized with nitric acid or a strong solution 
of acid nitrate of mercury, followed by water-dressings. 
Afterward the part may be dressed with iodoform or aristol. 
Bandaging, strapping with mercurial plaster, and the use 
of rubber cots are also useful methods of treatment. 

In ingrowing toe-nail the nail should be filed down the 
middle, or, if that does not relieve the pressure, it may 
have to be removed in part or entire. The insertion of 
borated lint between the nail and the nail-fold, or using 
boric acid in powder first and some threads of lint or a 
little absorbent cotton to separate the parts, and strapping 
the toe with adhesive plaster, will also answer well. If 
ulceration has taken place, the ulcerated surface should be 
dressed with iodoform or aristol. If the ulceration be 
covered with exuberant granulations, they should be 
touched with the nitrate of silver stick. As a preventive 
of the trouble, wearing well-fitting shoes and keeping the 
nails clean and cut down the middle are the best means at 
our command. 

Paxton's Disease. See Tinea nodosa. 

Pediculosis. Synonyms : Phthiriasis ; Morbus pedicu- 
laris ; Pedicularia ; Lousiness. 

Symptoms. There are three varieties of lice that infest 
the human species, namely, the pediculus capitis, pediculus 
vestimentorum, and pediculus pubis. Though they all 
belong to one family, they differ among themselves, and 
have distinct regions which they invade. 

The pediculus capitis infests the head only, and of that 
the occipital region is the common seat of invasion. 
From there it generally spreads to the parietal region, 
which is one of the best places in which to seek for nits, 
and, maybe, all over the scalp. The lice cause irritation 
of the scalp both by their movements and by the insertion 
of their haustellum into follicles of the skin for feeding- 
purposes. Lice have no mandibles. There is no such 
thing as a louse-bite. They simply suck their nutriment 
by inserting their haustellum into the follicles of the skin. 



412 DISEASES OF THE SKIN. 

The victim scratches to relieve the itching and irritation, 
and this gives rise to a dermatitis of eczematous character 
with the production of large pustules. A fully developed 
and characteristic case shows the hair in the occipital region 
matted together with a sticky secretion and, it may be, blood- 
crusts, more or less eczematous lesions and scattered pus- 
tules over the whole scalp, enlarged lymphatic glands in 
the neck, and perhaps a few small pustules on the neck 
and face. When a patient presents himself with a pustular 
eruption on the neck, or with a number of large, crusted 
pustules scattered over the scalp, pediculosis capitis should 
always be suspected, and search made for the pediculi or 
their nits upon the occipital and parietal regions. Very 
often no pediculi can be found ; but if the disease is pedicu- 
losis, the nits will be discovered in the localities mentioned. 
The pediculus vestimentorum, or body-louse, inhabits the 
seams of the clothing, where it lays its eggs, and which it 
leaves only for the purpose of feeding upon the skin. It 
inserts its haustellum into the follicles of the skin, and 
thus produces a small hemorrhagic spot, even with the 
surface of the skin, which is a pathognomonic lesion of 
the disease. This feeding gives rise to itching, and the 
victim scratches to relieve it, thus producing a second 
symptom, excoriations. These have one peculiarity, which 
is, that they are very apt to take the form of long, parallel 
scratch-marks, because the patient digs into his skin with 
all four nails at once. Moreover, as the lice live by prefer- 
ence in the shirt-band at the back of the neck, these long 
scratch-marks are most often seen over the shoulders. 
Whenever they are seen we should suspect lice. Excori- 
ations are also seen on the inside of the limbs in locations 
corresponding to the seams of the clothing and about the 
waist corresponding to the location of the waist-band. In 
certain individuals, besides excoriations and hemorrhagic 
specks, we will find ecthymatous pustules, ulcerations, and, 
in very old cases, a great deal of pigmentation, so that 
the skin appears as if affected with a general chloasma. 
Any of these symptoms — hemorrhagic specks, excoriations, 
and itching, which is incessant in pronounced cases — should 
lead us to suspect lice, and a careful search of the seams 



PEDICULOSIS. 413 

of the clothing will reveal them, unless the patient has 
changed everything before coming to us. It must be re- 
membered that the lice dwell both in linen and woollen 
clothing, and, in bad cases, in the bedding also. W. A. 
Jamieson l has found in many cases that the lanugo hairs, 
especially on the back and shoulders, have nits on them, 
and believes that this fact accounts for the relapses often 
seen in the disease. 

The pediculus pubis, crab-louse or morpion, has a far 
wider feeding-range than the other varieties. Though its 
favorite feeding-ground is the pubic region, it may be met 
with upon the hair of the abdomen, chest, axillae, beard, 
eyebrows, and eyelashes. Itching, excoriations, and ec- 
zematous lesions are the symptoms it gives rise to, though 
the disturbance is not so great as that caused by the other 
forms of lice. It is the least common variety. It requires 
careful search and a sharp eye to discover the vermin at 
times, as they are almost transparent, and usually are 
attached to the hairs head downward, and close to the 
skin. Cobbold taught that the pediculus that inhabits the 
eyelashes was a distinct species, the pediculus palpebra- 
rum ; but by most authorities the distinction is not made. 
In some cases, instead of red punctate marks, we find dull 
or slaty-gray, or pale-blue, lentil- to split-pea-sized mac- 
ules scattered over the pubes, abdomen, extensor surface 
of the arms, axilla?, and inside of the thighs. These are 
known as macules cczrulece, or taches ombrees. They do 
not disappear on pressure. They last for a few days, and 
then disappear of themselves. To give rise to these spots 
there must be a predisposition on the part of the skin. 
Most of the few reported cases have been in debilitated 
subjects. According to Duguet, 2 the macules are produced 
by the emptying of the contents of the salivary glands of 
the louse beneath the human epidermis. 

Etiology. These different varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig. 54) is 
about two millimeters long and one millimeter broad, with 
a triangular head and broad thorax and short legs. The 

^rit. Journ. Dermat., 1899, xi., 193. 
z Gaz. des'H6p., 1880, liii., 362. 



414 DISEASES OF THE SKIN. 

body-louse (Fig. 55) is larger than the head-louse, being two 
or three millimeters long, with a more oval head and longer 
legs with more developed claws. The pubic louse is 
broader and flatter than either of the others, with rounder 
head, longer, stronger, and more claw-like legs, resembling 
somewhat a crab (Fig. 56). The color of the lice is gray 
or white. They propagate with great rapidity, the young 
hatching out in six or seven days, and being capable within 
eighteen days of propagating their species. It has been 
calculated that two female lice might become the grand- 

Fig. 54. Fig. 55. 





Pediculus capitis.— Male. Pediculus vestimentorum. 

(After Kvchenmeister.) (After Kuchenmeister.) 

mothers of 10,000 lice in eight weeks' time. The pedicu- 
lus capitis deposits its eggs close to the scalp and secretes 
a glue-like substance that sticks the ova to the hair. There 
may be but a single ovum on a hair, or many of them. The 
distance of the nit from the scalp shows the length of time 
that the disease has existed. As it takes the hair about a 
month to attain the length of three-fourths of an inch, if 
we find the nit that distance from the scalp we know that 
it was deposited at least one month before. The severity 
of the symptoms to which the lice give rise will vary with 
the individual, some people being far more susceptible than 
others. Infection takes place from other people or from 



PEDICULOSIS. 



415 



infested body or bed clothing. Women and children are 
the most frequent victims of pediculosis capitis ; adults, 
and especially elderly people, of pediculosis vestimento- 
rum. Pediculosis pubis is most frequently contracted from 
impure sexual intercourse, and is, therefore, most common 
in young adults. Dirt and uncleanness favor all forms, 
though even the most cleanly may at times harbor vermin. 
Diagnosis. Pediculosis capitis needs to be diagnosti- 
cated from eczema. The characteristic location of its 
lesions upon the occipital region and nape of the neck, 
with its scattered and discrete large pustules over more or 

Fig. 56. 




Pediculus pubis. (After Schmakda.) 



less of the scalp, should always suggest pediculosis; then, 
if the lice or their ova are found by searching the hair, 
the diagnosis is established. Nits here, as elsewhere, are 
differentiated from epidermic scales by being located 
upon the side of the hair, while the scale has a hair 
passing through its center (Fig. 57). The nit, too, is of 
a yellowish color, somewhat pear-shaped, with its larger 
rounded end upward; and it adheres closely to the hair, 
so as not to be readily removed. It is not always easy to 
distinguish pediculosis vestimentorum from pruritus cuta- 
neus, especially if at the time the patient presents himself 
he has clean clothes on throughout. Both may occur in 



416 



DISEASES OF THE SKIN. 



Fig. 57. 



elderly people, and both may last a long time with no 
other lesion than scratch-marks. In pruritus we may find 
evidences of atrophic skin changes; the itching is often 
paroxysmal, and made worse by the patient becoming 
overheated. If we find the parallel 
scratch-marks over the shoulders and 
the hemorrhagic specks, we can make 
a positive diagnosis of pediculosis. 
From urticaria pediculosis vestimen- 
torum differs in having hemorrhagic 
specks and in the parallel scratch- 
marks. Urticaria may complicate a 
pediculosis. Scabies differs from pedic- 
ulosis in appearing by preference upon 
the anterior face of the wrists, upon the 
breasts in females, upon the penis of 
males, and about the umbilicus of both 
sexes. Its lesions are not long, par- 
allel scratch -marks, but small scratched 
papules. If the lice or their ova can 
be found in any case, the diagnosis of 
pediculosis is made easy. Dermatitis 
herpetiformis differs from pediculosis in 
wanting the parallel scratch-marks and 
in the markedly grouped character of 
its lesions. There will often be found 
groups of vesicles scattered about the 
skin. There can be no difficulty in 
diagnosing pediculosis pubis. Any 
itching about the pubic region should 
lead to an investigation, which, if care- 
fully made, will reveal the pediculi or 
their nits. 

Treatment. The most ready means 
of curing the disease when in the hairy 
regions is to shave the hair off and make some emollient 
application to the scalp to cure the eczema. But this is 
not advisable, excepting in children and in men in hos- 
pitals, and is not necessary. The most speedy and prac- 
ticable method in public practice is to soak the hair of the 



Ova of head-louse at- 
tached to hair. (After 
Kaposi.) 



PELLAGRA. 417 

head or pubic region with raw petroleum or kerosene, with 
or without diluting it with sweet oil. This may be done 
night and morning for two days, and the parts then washed 
with soap and water. This will effectually kill all the 
lice, and probably destroy the life of the ova. The latter 
must be removed for fear that they are not dead, and for 
this purpose we may use a fine-toothed comb to the hair 
or pull the hair through a cloth saturated with vinegar or 
dilute acetic acid, which will soften the glue-like substance 
of the nits. No attention is to be paid to the dermatitis 
until after the cause of it is removed, when it will rapidly 
get well under any simple treatment. In private practice 
an infusion or tincture of delphinium staphisagria (lark- 
spur seeds), or a ten per cent, solution of carbolic acid, or 
a half to one per cent, solution of bichloride of mercury, 
may be substituted for the petroleum. The bichloride 
should not be used if there is much dermatitis. The oint- 
ment of the ammoniate of mercury is efficient, but, as a 
rule, an ointment should not be used on hairy parts. Blue 
ointment is a well-known remedy for pediculosis pubis, 
but it is apt to set up a dermatitis that is undesirable, and 
should not be prescribed. 

For pediculosis vestimentorum there is no use in mak- 
ing any application to the skin. The woollen clothes 
should be baked in a hot oven, and the underclothing and 
sheets should be well boiled. If this cannot be done, or 
new clothes obtained, powdered sulphur or staphisagria 
may be powdered in all the seams of the clothing, and a 
five per cent, ointment of carbolic acid applied to the body. 
Jamieson recommends smearing the whole body in all 
cases with paraffin and then giving a warm carbolic acid 
bath. 

Pelade. See Alopecia areata. 

Peliosis Rheumatica. See Purpura. 

Pelioma Typhosum. See Macula? cserulese. 

Pellagra. Synonyms : Risipola lombarda ; Mai de la 
rosa ; Mai roxo ; Lombarclian leprosy. 

Symptoms. But few eases of this disease have been 



418 DISEASES OF THE SKIN. 

reported in this country. Since the number of Italians 
is constantly increasing here it is important for us to be 
able to recognize the disease. It has prodromal symptoms 
of progressive weakness, intestinal catarrh, lassitude, gid- 
diness, headache, and burning sensations in back, limbs, 
hands, and feet. These make their appearance in the 
spring, and shortly after an erythema affects the back of 
the hands down to the articulation of the first and second 
phalanges, the back of the wrists and forearms up to the 
elbow, the back of the feet, if the person goes barefoot, 
the front of the neck and chest to the lower edge of the 
first piece of the sternum, and, in women and children, the 
forehead, nose, and cheeks — that is, all those regions ex- 
posed to the sun. The color is bright, dark, or livid red, 
and is not a simple erythema, as the color cannot be made 
to disappear completely under pressure. The skin is 
often so swollen as to prevent all work. Bullae may form 
upon the affected parts and be followed by erosions. In 
a few weeks desquamation begins, but the skin continues 
discolored and thickened up to July or August, when a 
gradual decline of all the symptoms takes place. During 
the winter the patient may appear quite well, but a re- 
lapse is pretty sure to occur during the next spring, and 
to recur each succeeding spring with ever-increasing sever- 
ity of all the symptoms ; the patient emaciates, loses 
strength, develops grave cerebro-spinal neuroses, sinks into 
a typhoid state, and dies. The skin becomes atrophied, 
smooth, shining, cracked, or it may be thickened. There 
is a loss of cutaneous sensibility, and the erythematous 
redness gradually extends over the whole surface of the 
body. The average duration of the disease is five years. 

Etiology. The disease is endemic in northern and 
central Italy, especially in Lombardy, Venetia, and 
^Emilia ; in the southwestern part of France, and in the 
northern part of Spain. It may occur any where. Women 
are most subject to it, children least so. It seems to be 
a disease fostered by poverty, want, and bad hygiene, and 
to be induced by an almost exclusive diet of decompcrsed 
or fermented maize, or, possibly, other grains. Some cases 
have been traced to the drinking of spirits made from 



PEMPHIGUS. 419 

damaged maize. It is, therefore, similar in origin to ergot- 
ism. It is not contagious or hereditary. 

Diagnosis. A suspicion of a case being one of pellagra 
should be aroused whenever an erythema upon the ex- 
posed parts is met with in a person coming from the 
regions in which the disease is known to be endemic, 
especially if it is combined with more or less lassitude and 
hebetude. 

Treatment. The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the effi- 
cacy of arsenic for adults, and frictions with chloride of 
sodium solution in children. 

Pemphigus. Synonyms : Pompholyx ; (Ger.) Blasenaus- 
schlag ; (Ital.) Pemfigo. 

A chronic disease of the skin characterized by the 
eruption of successive crops of bullae upon the apparently 
sound skin and with either transient or no antecedent 
erythema. 

At one time every bullous eruption was a pemphigus, 
but with more careful observation and study a number of 
bullous eruptions have been established as distinct diseases. 
Many cases now included under dermatitis herpetiformis 
used to be regarded as pemphigus. It is probable that 
this process of elimination will continue. In the mean- 
time a considerable degree of uncertainty pervades our 
knowledge of the disease, both as to its symptomatology 
and etiology, and we can only stand and await further de- 
velopments. While in this attitude we must have some 
sort of a chart to guide us, and it has been my object to 
draw its lines with as great sharpness as possible. 

The disease is a rare one in this country, only 385 cases 
being reported in a total of 309,406 cases in the statistical 
tables of the American Dermatological Association from 
1877 to 1897. 

Symptoms. It is usual to describe two varieties of 
pemphigus, namely, pemphigus vulgaris and pemphigus 
foliaceus. Besides these we have pemphigus vegetans and 
pemphigus neonatorum. 

Pemphigus Vulgaris may begin with an outbreak of 



420 DISEASES OF THE SKIN. 

bullae or there may be more or less constitutional disturb- 
ance 'before their' appearance. The latter condition is 
more often seen in debilitated subjects, children, and old 
people, and consists in chilliness, nausea, and, perhaps, a 
rise of two or three degrees of temperature. These con- 
stitutional disturbances may occur before the appearance 
of each crop of bulla?. The characteristic eruption is an 
outbreak of two or more up to a hundred or more pin- 
head-sized vesicles that in a few hours develop into tense, 
oval, hemispherical, prominently raised, fully distended 
bulla with translucent contents. The size of the bullae 
varies; it may be but one-eighth of an inch in diameter, 
or by the coalescence of several neighboring bullae, large, 
irregular ones of two or three inches in diameter may be 
formed. One distinguishing feature of these bullae is that 
they have no areola, but spring up at once from the 
seemingly healthy skin. Their contents soon become tur- 
bid or perhaps purulent, and then a slight inflammatory 
halo may form. Rarely hemorrhage into the bullae oc- 
cur* The bulla? do not tend to rupture spontaneously, 
but to dry up, and leave the dried cover as a crust. 
If th'ey are ruptured accidentally, an excoriated place is 
left that heals more or less readily, according to the general 
condition of the patient. Some pigmentation may be lett 
for a time to mark the site of the bullae. 

This eruption may take place anywhere, but affects par- 
ticularly the lower part of the face, the trunk, and limbs. 
It is usually bilateral, and may be roughly symmetrical. 
The life of the individual bulla is two to eight days ; but 
while one crop is disappearing a new one occurs, and the 
duration of the disease may thus be measured by weeks or 
months. Sometimes there is an interval of weeks or 
months between the outbreaks. In favorable cases a few 
crops appear, and that is all, the patient making a good 
and complete recovery. In less favorable cases, or when 
the eruption is very extensive, frequent relapses and many 
excoriations take "place, the patient's strength becomes 
exhausted by the constant drain upon his system and loss 
of rest on account of the discomfort of his condition : ; he 
may die in a typhoid state, or of some intercurrent affec- 



PEMPHIGUS. 421 

tion. A number of cases of death from the disease within 
two or three weeks have been reported, and to these the 
name of acute 'pemphigus is given. A few authorities have 
reported acute bullous eruptions running their course in 
three to six weeks as acute pemphigus. Many of these 
cases were probably cases of bullous erythema, as in them 
a preceding erythema is noted in the reports of the cases. 
Most cases run a chronic course, extending over months or 
years. 

In rare instances a diphtheritic membrane may form at 
the site of the bulla, or, instead of healing taking place, a 
gangrenous process may be set up, with considerable 
destruction of tissue, or hemorrhage may take place in 
some of the bullse. 

Neumann has described as pemphigus vegetans a bullous 
eruption in which healing does not take place, but the 
base becomes covered with sprouting granulations and 
assumes an uneven surface marked by furrows and secret- 
ing a thin fluid. The raw patches thus formed spread 
slowly at their circumference, and neighboring ones coa- 
lesce. In women the first lesions are usually seen about 
the vulva, and from there the disease spreads over the 
genito-anal region. In all cases the regions affected are 
the axillae, the root of the neck, the hands and feet, 
elbows, and scalp. It never becomes universal. Pig- 
mentation in points often follows the drying up of a 
bullse. The disease proves progressive ; marasmus and, 
finally, death closes the scene. Most of the cases are in 
syphilitics. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the patient. The conjunctiva 
is not spared, and if attacked serious deformity results. 

Cases of pemphigus neonatorum have been reported 
from time to time, and epidemics of it have been described. 
These are so evidently septic in origin that they hardly 
admit of being classified under the heading of pemphigus. 
Careful reading of not a few outbreaks of contagious 
pemphigus reported in the German journals will convince 
one who is acquainted with the bullous form of contagious 



422 DISEASES OF THE SKIN. 

impetigo that a mistake in diagnosis had been made by the 
reporter. Still, until further evidence is forthcoming, it is 
probably advisable to allow that both of these varieties of 
the disease do exist. Pemphigus pruriginosus is another 
variety made by writers. It fits in quite well under 
Duhring's dermatitis herpetiformis. 

Pemphigus Foliaceus differs considerably from pemphi- 
gus vulgaris. It may begin as such or it may develop 
from pemphigus vulgaris. Behrend 1 teaches that the 
difference between the two forms is simply a matter of 
coherence between the epidermis and corium, this being 
so slight in pemphigus foliaceus that we have a flaccid 
bulla instead of the tense, fully distended one of pemphi- 
gus vulgaris. 

Pemphigus foliaceus is much the more rare variety of 
the disease, Crocker giving its occurrence as one in five 
thousand cases. Its characteristic lesions are flaccid 
bullae, with opaque contents, that soon rupture and leave 
raw, moist surfaces with an edge of ragged epithelium. 
The fluid of the bulla? changes its position with the posi- 
tion of the patient, always seeking the most dependent 
part, and soon becomes purulent. After the disease has 
existed some time the patient emits a sickening odor on 
account of the large amount of raw surfaces of the 
ruptured bullae that are bathed with sero-pus. Affecting 
at first only a limited space, by degrees the disease spreads 
so that the whole body-surface becomes red and weeping, 
looking like eczema rubrum, with crusts and areas of 
ragged epithelium. The palms and soles are often spared 
on account of the thickness of their epidermal coverings. 
When the skin is thus generally involved, it is difficult to 
establish the fact of the occurrence of new bullae. The 
mucous membranes of the mouth and pharynx are affected 
in like manner, becoming converted into raw patches. 
The hair falls out ; the nails become thinner, brittle, 
atrophied, and, it maybe, drop off; and ectropion is apt to 
result from contraction of the skin about the eyes. The 
mucous membranes are also attacked, which greatly adds 
to the patient's discomfort. 

1 Viertdjahr. f. Dermat. u. Sypli., 1879, vi., 191. 



PEMPHIGUS. 423 

The condition of the patient is most deplorable in these 
extensive cases : his skin is stiff and sore, and perhaps 
smarts ; and after months or years he succumbs to the 
drain on his system, sinks into a typhoid state, and dies. 
During the early part of the disease there may be no con- 
stitutional disturbance. But eventually death is quite 
sure to result, if not from the disease, from some inter- 
current affection against which the patient is unable to 
offer any resistance. 

Etiology. We know very little about the causes of 
pemphigus. The tropho-neurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after 
all, the true one. Experiments have demonstrated that 
bulla? can be made to form by operations on the spinal 
cord, and observation has shown that bulla? do form in 
certain spinal diseases. Both sexes are subject to the 
disease. Children are more often affected than adults. 
The septic origin of certain bullous eruptions has already 
been spoken of under the heading of pemphigus neona- 
torum, and a number of cases of acute pemphigus occur- 
ring in butchers and in those engaged in handling meats 
have been reported by G. Pernet and W. Bullock. 1 All 
these ended fatally in a few days. Bullous eruptions are 
hereditary in some families, and in some subjects follow 
slight injuries to the skin. This is named Epidermolysis 
bullosa, which see. Chilling of the body seems to have been 
the exciting cause of some cases. Most subjects of the 
disease are debilitated. Some have advanced the theory 
that an excess of ammonia in the blood or defective kidney- 
elimination is the cause of the disease. Attacks of the 
disease have been observed to occur with each new preg- 
nancy in some women. 

Pathology. " Most authors regard the actual for- 
mation of the bulla as due to an inflammation of the 
papillary layer, with outpouring of fluid from the vessels ; 
but Auspitz calls it an akantholysis, or loosening of the 
prickle-cell layer, by the sudden escape of fluid from the 
vessels, destroying the young prickle-cells and lifting up 
the epidermis as a whole. Any inflammatory phenomena, 
1 Brit. Journ. Dermat., 1896, viii., 157. 



424 DISEASES OF THE SKIN. 

he thinks, are secondary." (Crocker.) Micro-organisms 
have been found in the fluid both of the bullae of chronic 
and acute pemphigus, and a peculiar diplococcus has been 
demonstrated by several observers in apparent causal re- 
lation to the disease. 

Diagnosis. If we regard the pathognomonic symptoms 
of pemphigus vulgaris as fully distended bulke springing 
up out of the sound skin without any antecedent erythema 
and without inflammatory halo, and occurring in crops so 
as to run a chronic course, then little difficulty will arise 
in diagnosis. A bullous erytliema has bulke arising upon 
an erythematous base or with erythematous lesions else- 
where,and runs a comparatively acute course. Dermatitis 
herpetiformis differs from pemphigus in the grouping and 
multiformity of its lesions, and the great amount of itch- 
ing that attends it. No matter how long it has lasted, it 
is seldom attended by the constitutional disturbances that 
are met with in pemphigus chronicus. In bullous urti- 
caria the bulla rises upon a wheal. The bullous form of 
impetigo contagiosa will be quite sure to present the char- 
acteristic impetigo pustules upon the hands or face, and 
search will probably discover some child with impetigo 
with whom the patient has come in contact. Varicella 
bullosa occurs epidemically, and runs a short course. 

Pemphigus foliaceus when in its early stage, and affect- 
ing but a small area, is readily diagnosed by the occur- 
rence of its flabby bulla?, arising without antecedent in- 
jury. After it has lasted long enough to involve a large 
area it is with difficulty differentiated from eczema rubrum 
and dermatitis exfoliativa. In fact, without the history of 
the case it is sometimes almost impossible to make the 
diagnosis. It may be differentiated from eczema rubrum 
by its crusts being made less of dried exudation than of 
epithelium, by the slighter amount of exudation, by the 
ragged look of some part of the disease, and by careful 
watching for and finding the large flaccid bulla? which will 
be sure to appear if the case is one of pemphigus. More- 
over, a universal eczema rubrum is very rare, and the itch- 
ing is more pronounced. Dermatitis exfoliativa differs from 
pemphigus in the absence of moisture and of bulla?, and 



PEMPHIGUS. 425 

inthe thinness of the exfoliated epidermis. Lichen ruber acu- 
minatus is perfectly dry and presents characteristic papules. 

Treatment. The drug upon which most reliance is 
placed in the treatment, of this disease is arsenic. We 
may use Fowler's solution; or arsenious acid in pill-form, 
as the tablet triturate with piperina, or the Asiatic pill. 
Whatever form is given, it is advisable to begin with 
small doses and gradually increase them until the limit of 
tolerance is reached or the disease is controlled. Unfor- 
tunately it often disappoints us in its effects. Attention 
to diet and hygiene, and the general condition of the patient, 
with the judicious use of tonics, such as quinine, iron, and 
cod-liver oil, will often do as much, if not more, than 
arsenic to cure the patient. 

Locally, dusting powders of oxide of zinc, starch, ly- 
copodium, or bismuth in varying combinations; lotions of 
lime-water, borax, zinc, liquor plumbi subacetatis, and 
the like, prove helpful in allaying irritation and discom- 
fort. Lassar's paste is also a good application. Unna 1 
recommends equal parts of linseed oil, lime-water, oxide 
of zinc, and chalk, both to dry up the bullae and prevent 
their return. Linimentum calcis with one minim of creo- 
sote to the ounce is recommended by Hardaway. The 
continuous warm bath has afforded great relief in the 
Vienna hospitals. The bulla? may be opened if they are 
troublesome. Alkaline and antiseptic mouth-washes will 
afford relief where the mucous membranes are affected. 

Pro&nosis. The chances of recovery are uncertain. 
While many cases of pemphigus vulgaris recover, relapses 
are the rule, and if the patient is not strong, or the disease 
has lasted a long time, a guarded prognosis should be 
made. Hemorrhagic, diphtheritic, or f ungating bullae are 
of bad augury. Pemphigus vegetans, pemphigus foliaceus, 
and pemphigus acutus arising from infection are almost 
invariably fatal. 

Pemphigus Acutus Contagiosus. See Impetigo contagiosa. 

Pemphigus Gangrsenosus. See Dermatitis gangrsenosa 
infantum. 

1 Monatshefte f. prakt. Dermat., 1888, vii., 108. 



426 DISEASES OF THE SKIN. 

Perforating Ulcer of the Foot is an accident liable to 
occur in those in whom the nerve-supply of the foot is 
deficient, as in locomotor ataxia, syphilis, leprosy, and 
peripheral neuritis. The most common location for the 
ulcer is at the metatarso-phalangeal articulation of the 
great or little toe, or the cushion of the great toe. It may 
be only on one foot, or both feet may be affected. The 
process is slow, beginning as a proliferation of the epi- 
dermis like a corn, under which suppuration takes place, 
and an nicer is left. This goes deeper into the tissues, 
until a sinus forms that reaches to the bone. The edges of 
the ulcer are hard. Usually there is little pain, though 
there may be hyperesthesia of the surrounding parts. 
This painlessness distinguishes it from a suppurating corn. 
The palms may be affected in the same way as the soles. 
The disease is very intractable, and must be managed on 
surgical principles, amputation of the whole or part of the 
foot being required in some cases. Death may result from 
the disease. 

Under the name of Hand and Foot Disease Hyde 
reports 1 three cases of ulcerations of the hands and feet 
that he regards as due to tropho-neurotie disturbances. In 
these cases, with or without functional disturbances, such 
as hyperidrosis and coldness of the hands and feet, bromi- 
drosis, local anaesthesia, vertigo, faintness, and rheumatic 
pains, there were found various grades of dystrophia un- 
guium, from roughness to onychogry pilosis, tender and 
painful or insensitive maculations of the hands and feet, 
pigmentary patches on the palms and soles or the back of 
the hands or feet, or both ; different dermatoses, such as 
erythema, eczema, ichthyosis, local alopecias, hypertri- 
chosis, symmetrical tylosis, with or without spontaneous 
exfoliation or recurrence. After a time ulcerations formed 
on the hands or feet, or on both hands and feet. 

Periadenitis Sudoripara. See Abscess of sweat glands. 

Perifolliculitis Suppurees et Conglomer^s en Placards. 
Under this lengthy title Leloir 2 has described and figured 

1 Pliila. Med. News, 1887, li., 410. 

2 Ann. de derm, et de sypli., 1884, v., 437. 



PERIFOLLICULITIS. All 

a rare disease of the skin which specially affects the back 
of the hands. 

Symptoms. It seems to commence as a diffused red 
patch upon which develop small pustules, which itch 
slightly; or as small, red, more or less conglomerate, 
slightly itching elevations that form patches. The patches, 
however formed, are sharply defined, raised from two to 
five millimeters, round or oval, flattened, and of red, 
vinous, violaceous, or blue color. They vary in size from 
that of a ten-cent piece to that of a silver dollar, and are 
often crusted. When the crust is removed, the exposed 
surface is smooth or mammillated, but never papillomatous ; 
and riddled with a number of pin-point- to pinhead-sized 
openings, corresponding to glandular orifices, many of 
which are closed with a plug of greenish, dried pus. 
Beside these openings there are a number of greenish 
points that are ready to become such whenever the epi- 
dermis over them is removed. At a more advanced 
stage the openings form small pinhead-sized ulcers. By 
compression of the patch these openings give vent either 
to a drop of pus or serous fluid, or little, elongated, 
vermicelli-like whitish masses. In still more advanced 
cases the patches become more elevated, fluctuation mani- 
fests itself, and sero-pus may be expressed. The patches 
are usually single, but may be multiple. The back of 
the hand and wrist are the usual locations of the disease ; 
but it may occur upon the dorsum of the foot or the outer 
side of the thigh, or be disseminated, but chiefly located 
on the extremities. The course of the disease is acute. 
It is fully developed in eight days ; it then continues a 
week or two and disappears in about twelve days more. 
If badly treated, it may last longer, and be followed 
by a papillary condition. It is unattended by subjective 
symptoms, except slight itching. It leaves either no 
trace of itself, or a delicate superficial cicatrix that dis- 
appears, or a slight staining that soon fades. The hair 
is unaffected, though the disease may involve its fol- 
licles. 

Pathology. The disease is a purulent inflammation 
of the skin follicles, specially of the lanugo hairs, and the 



428 DISEASES OF THE SKIN. 

pilo-sebaceous follicles of regions deficient in true hairs. 
It is possibly raicrobic in origin. 

Diagnosis. The disease is diagnosed from tnclw- 
phytosis by its more rapid course, and recovery under 
simple treatment ; by the hair being unaffected ; and by 
the absence of the trichophyton in the hair. Anthrax 
differs from it in the more pronounced character of its 
local and general reaction, its central core, and inflamma- 
tory induration. Tuberculosis verrucosa cutis is much 
slower in its evolution, is serpiginous, and does not yield 
to simple treatment. Eczema differs from it in not haying 
such sharply marked borders ; in wanting the characteristic 
openings and livid tint; and in having more pronounced 
itching, a mucous, sticky discharge, and a comparatively 
long duration. 

Treatment. The treatment is simple and consists in 
squeezing out the pus once a day, bathing the part for 
half an hour in warm carbolized water or a solution of 
boric acid, and covering with an antiseptic dressing. If 
papillae have formed, they should be scraped off, and 
the surface touched with nitrate of silver. In some 
obstinate cases it may be necessary to scrape out the whole 
patch. 

Perionyxis. See Paronychia. 

Perleche. According to Brocq, this is a disease occur- 
ring in infants and affecting the commissures of the lips. 
Their epithelium is pale, macerated, desquamating, while 
the skin underneath is red and slightly inflamed. Some- 
times fissures will form that are painful, and may bleed 
when the patient widely opens his mouth. The inflamma- 
tion may spread to the neighboring regions. It runs a 
course of two or three weeks, but is subject to relapse. It 
is contagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip met 
with in svphilis, but is marked by an absence of all other 
symptoms of svphilis. 

The treatment consists in touching the diseased parts 
with sulphate of copper or alum, or an antiseptic solution, 
and in carefully looking after the nursing-bottles. 



PIEDRA. 429 

Pernio. See Dermatitis calorica. 
Pfundnase. See Hypertrophic rosacea. 

Phagmesis. A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. See Pediculosis. 

Pian. See Yaws. 

Pian Ruboide. See Dermatitis papillaris capillitii. 

Piebald Skin. See Leucoderma. 

Piedra. Synonyms : Tinea nodosa ; Trichomycosis 
nodosa. 

Symptoms. This disease, or deformity of the hair, is 
said to occur only in Cauca, one of the United States of 
Colombia, and was first described in 1874 by Dr. N. 
Osorio, of the University of Bogota. It consists in the 
occurrence along the shaft of the hair of from one to ten 
small dark-colored nodes which are very hard and gritty, 
and rattle like stones when the hair is combed or shaken. 
The stony hardness of the nodes gave the disease its 
name " Piedra," which is the Spanish for " stone." These 
nodes are always placed at irregular intervals along the 
hair-shaft, beginning at about half an inch from the point 
of exit of the hair, the root being unaffected. The disease 
occurs most commonly in women, men being rarely affected, 
and it is the head-hair alone which exhibits these nodes. 
The disease is non-contagious, and is met with only in 
warm valleys. 

Etiology. Dr. Osorio thought that the nodes were 
produced by an agglomeration of epithelium in certain 
parts of the hair. Mr. Morris l believes it is due to the 
use of a peculiar mucilaginous linseed-like oil, which is 
used particularly by the native women to keep their hair 
smooth and shiny. Another theory is that it is clue to the 
use of the water of certain stagnant rivers which is very 
mucilaginous. Heat seems essential for its production, as 
the employment of either of these fluids will not cause the 
disease in cold climates. 

1 Lancet, 1879, x., 407. 



430 DISEASES OF THE SKIN. 

Microscopical examination of the affected hair shows 
that the nodes consist of a honeycombed mass of pig- 
mented spore-like bodies, the whole mass arising from 
one cell which sends out spore-like columns radially 
in all directions. As soon as the cells have reached a 
certain size they seem to alter their shape, become darker 
in color, and form a pseudo-epidermis. It is, therefore, 
a fungous growth. The nodes were found to be very 
hard to cut, and when considerable force was used they 
broke. 

Diagnosis. Piedra differs from trichorrhexis nodosa in 
the stony hardness of the nodes, in its occurring principally 
upon the head-hair, in its probable etiology, and in the 
microscopical appearances it presents. 

Treatment. — By the use of hot water the nodes can 
be entirely removed. 

Pigmentary Mole. See Naevus pigmentosus. 

Pigmentgeschwulst. See Melanotic sarcoma. 

Pigmentkrebs. See Sarcoma. 

Pigmentmal. See Nsevus pigmentosus. 

Pimples. See Acne. 

Pinta. Synonyms : Mai de los pintos ; Tinna ; Caraate 
or cute ; Quirica ; Spotted sickness. 

This disease occurs only in southern Mexico, Panama, 
and South America. 

Symptoms. According to Crocker, from whose work 
this account is drawn, it consists of scaly spots varying in 
color, shape, number, and size. They show themselves 
first on the uncovered parts, but may affect any or all of 
the cutaneous surface. The disease spreads by the periph- 
eral extension of old patches and the formation of new 
ones. The patches are round or irregular in shape, 
sharply or ill defined, and of black, gray, blue, red, or 
dull-white color. The red and white patches are deeper- 
seated than the others, being located in the rete and 
corium. The patches may be of uniform color or of 
different tint, but do not change their color after they 



PITYRIASIS ROSEA. 431 

have once formed. They are scaly and usually feel rough 
and dry. The hair grows gray and falls. There is some 
itching, and a bad odor emanates from the patient. The 
course of the disease is chronic and shows no tendency to 
recovery. 

Etiology. The disease is contagious, and its spread is 
favored by dirt and neglect. It is most common in the 
poor natives of Indian stock. It is of fungous origin, and, 
in fact, seems to be allied to chromophytosis. 

Treatment. The treatment is the same as for chro- 
mophytosis. 

Pityriasis Alba Atrophicans. This disease begins in 
early life as a partly lamellar, partly branny desquama- 
tion of the skin without redness or any other form of 
efflorescence. The skin may be affected wholly or in 
part. After lasting ten to fifteen years it is followed by 
secondary atrophy of the skin, which becomes thinner, and 
soft. The subcutaneous fat is lost and the veins show 
through. 

Pityriasis Lichenoides Chronica. This is the name given 
by F. Juliusberg 1 to a disease described by Neisser as 
Lichenoid and psoriasiform exanthem, and by Jadassohn 
as Dermatitis psoriasiformis nodularis. It consists in a 
polymorphic eruption, which may occur anywhere on the 
bocfy, though the scalp and face are nearly always free. It 
begins as red, pinhead-sized, flat, smooth papules. These 
flatten, and we have small patches with silvery- white, 
shining, delicate scales, resembling the scales of psoriasis. 
The eruption becomes better and worse, and is not amen- 
able to treatment. It is a parakeratosis with superficial 
inflammatory infiltration in the corium and papillae. 

Pityriasis Maculata et Circinata. See Pityriasis rosea. 

Pityriasis Nigricans. See Chromidrosis. 

Pityriasis Parasitaire. See Chromophytosis. 

Pityriasis Pilaris. See Keratosis pilaris. 

Pityriasis Rosea. Synonyms : Pityriasis maculata et 
* Arch. f. Dermat. u. Syph., 1899, 1., 359. 



432 DISEASES OF THE SKIN. 

circinata; Herpes tonsurans maculosus (Hebra); Roseola 
pityriaca'(Barduzzi) ; Pityriasis circine et margine (Vidal) ; 
Pityriasis rosee (Gibert) ; Erytheme papuleux desquamatif. 
An acute disease of the skin characterized by an erup- 
tion of rosy-red macules that enlarge intodry, scaly, oval 
or annular patches with rosy-red peripheries and chamois- 
yellow, wrinkled centers; it runs a definite course and 
terminates in recovery. 

Symptoms. Though Gibert described pityriasis rosea 
as early as 1868, the disease is but little known in this 
country, not because it does not occur, but because it is 
not recognized. It is one of the rarer skin diseases. 
Most writers tell us that its outbreak is preceded by slight 
constitutional disturbances, such as malaise, loss of ap- 
petite, and headache, with a slight rise of temperature just 
before the outbreak of the eruption. These symptoms, in 
my experience, have been as conspicuous by their absence 
as* in the case of impetigo contagiosa. The eruption itself 
most often begins upon the upper part of the chest a little 
above the breasts, or, according to Brocq, 1 at the level of 
the waistband, anteriorly and a little to one side, where he 
locates what he calls the " primitive patch." The primary 
lesions are miliary or small papules of pale-red color, sur- 
rounded by an erythematous zone. These soon enlarge into 
rosy-red, slightlv raised macules, and slowly increase periph- 
erally into oval or rounded patches witli well-defined bor- 
ders "raised somewhat higher than the centers. When the 
patches have attained a diameter of half an inch or more 
the centers begin to clear up by becoming of a yellow, old- 
parchment color, scaly and shiny, while the border is pale 
red. Later the center may disappear and rings only 
remain ; or if two or more patches meet at their borders, 
irregular gyrate figures may be formed. All the^ lesions 
do not attain the same degree of development, and in well- 
developed cases lesions in all stages will be found. The 
lesions are slightly scaly from the commencement, and the 
furfuraceous desquamation continues until the faint mark 
left by the lesion disappears. Itching, usually slight in 
amount and only when the person is warm, is the only 
1 Ann. de derm, et de syph., 1887, viii., 615. 



PITYRIASIS ROSEA. 433 

subjective symptom. Sometimes it is severe. The erup- 
tion is most marked upon the neck, infra- and supra-clavic- 
ular regions, sides of the chest, and shoulders ; it may be 
marked also on the abdomen and buttocks. The whole 
body may be involved, but the hands and feet are usually 
spared, and it is uncommon on the face. After some three 
to six weeks the disease tends to spontaneous recovery, 
although it may last for two months. 

Etiology. We know nothing about the cause of the 
disease. It affects all ages and both sexes. Crocker thinks 
that it is most common in children. Most of the cases I 
have seen have been in young adults. This difference may 
be accounted for by the fact that he has a large children's 
dispensary service. Some cases seem to be due to over- 
heating of the skin by wearing too heavy underclothing. 
Hyde and Montgomery teach that it recurs most often in 
blond subjects who have been enfeebled by great physical 
fatigue or over-study in school. The disease seems to occur 
epidemically in some instances, and cases are apt to present 
themselves in groups. Contagion has not been established. 
Bazin regards it as arthritic. It may be parasitic, but as 
yet the parasite awaits demonstration. Yidal l describes a 
parasite that he names the microsporon anomoeon, as found 
in pityriasis circine et margin^, a disease probably the same 
as pityriasis rosea. Hebra regarded it as a manifestation 
of trichophytosis, and some authorities still think that some 
cases are diffused ringworm. 

Diagnosis. Pityriasis rosea must be differentiated from 
the early circinate, scaling, macular syphiloderm ; annular 
psoriasis; seborrhoeal eczema; and disseminated trichophy- 
tosis. The one most distinguishing feature of pityriasis 
rosea is the wrinkled old-parchment yellow of the center 
of the ring. This is absent from the lesions of all the 
other diseases with which it is likely to be confounded. 
The syphilide is of a less bright-red color, and there surely 
will be some other evidence of syphilis to guide us. 
Psoriasis is far more scaly; the scales are of a white 
color ; the tips of the elbows and the anterior face of the 
knees will be specially affected ; and typical psoriatic 
1 Arm. de derm, et de svph., 1832, iii., 22. 



434 DISEASES OF THE SKIN. 

patches will be found somewhere. Seborrheal eczema 
occurs upon the middle sternal and interscapular regions 
particularly ; the patches have a greasy feel ; the scales are 
thicker than in pityriasis rosea ; and the lesions show little 
tendency to spontaneous involution. Cases occur in which 
it is very difficult to make the diagnosis between this and 
pityriasis rosea. In trichophytosis the fungus is readily 
found under the microscope, which is a decisive test. 
Apart from that, ringworm does not spread so rapidly nor 
involve such wide areas. 

Treatment. Pityriasis rosea is a self-limited disease, 
and recovery is sure to take place in a short space of time. 
Though treatment seems not to have any marked effect on 
the disease, we may use lotions of salicylic acid, ten to 
twenty grains to the ounce, or of boric acid ; or content 
ourselves by allaying the itching with lotions of carbolic 
acid (ten grains to the ounce), calamine, oxide of zinc, and 
the like. Tepid alkaline or bran baths may be used, fol- 
lowed by a dusting powder. 

Pityriasis Rubra. See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. This disease was first de- 
scribed by the French writers. The following account is 
abstracted from an admirable paper by Besnier. 1 

It has been confused with lichen pilaris, psoriasis, lichen 
ruber and lichen planus, and pityriasis rubra. Several 
cases of lichen ruber reported in this country have been 
declared by the French to be cases of the disease under con- 
sideration, as well as the lichen psoriasis of Hutchinson. 
Kaposi regards it as the same as lichen ruber. It is prob- 
able that the two are identical. 

Symptoms. A typical case has three principal ele- 
ments : 1. Asperities of the follicular orifices ; 2. Desqua- 
mation ; 3. Roughness of the skin with exaggeration of 
its folds. The disease generally begins suddenly, without 
prodroma, but there may be some malaise, nervousness, 
insomnia, hvpersesthesia of the finger-ends, formication, 
and the like. These prodromata are of short duration, 
and rarely cause the patient to go to bed. The uncovered 
1 Ann. de derm, et de syph., 1889, x., 253 et seq. 



PITYEIASIS RUBRA PILARIS. 435 

parts are usually first affected with the eruption, but it 
may appear primarily upon the trunk or extremities. The 
initial lesion may be a simple exfoliation ; an erythema ; 
a scaling erythema ; a fine but scanty furfuraceous des- 
quamation ; a shiny redness with pityriasis ; desquamation 
of nail-bed, or fragility of nail. However beginning, the 
more pronounced form appears in a certain number of 
days or weeks, and may develop or abort at any point, or 
be limited to any region, or involve the whole body. 
When fully developed, a patch or the whole skin, as the 
case may be, presents the following characteristics : It is 
covered with elevations that are generally conical, but may 
present great diversity of shape. They may be discrete 
or coalesce. They may be so small as to be seen only by 
the aid of a microscope, or elevated many millimeters 
above the surface, with corresponding diameter. They 
are scaly, and vary in color from a silver white or gray to 
a bright or opaque red, red brown, or rosy yellow. Their 
summits may be flat, uneven, cone-shaped, or truncated, 
giving issue to a hair broken off at a little distance above 
the surface of the skin, and, it may be, sheathed by a cor- 
neous or sebaceo-squamous case. Instead of a hair pro- 
truding, it may form only a small comedo-like spot at the 
center of the summit, or it may be wanting, or it may seem 
to exist alone, giving to the region the appearance of a 
badly shaven beard. Sometimes the cone presents a crater, 
at the bottom of which is a black point, a punctured 
scaly plate, or a psoriatic point. When several elevations 
coalesce their borders disappear and they form a squamous 
patch, showing the central points and the associated 
pilary cones. The skin is scaly, dry, hard, rough like a 
file, and presents a "goose-skin" appearance. The scales 
may be scraped off without any loss of blood. The disease 
is generally symmetrical, but the lesions may be dissem- 
inated without order, or in irregular lines, groups, or 
islands, or may unite in tessellated areas. The cone-like 
elevations do not occur on the scalp, and are rare on the 
soles and palms. In these locations the disease takes the 
form of abundant desquamation upon a reddened base. 
AH other regions may be affected, the cones forming about 



436 DISEASES OF THE SKIN. 

the follicles of the skin, especially about the hair follicles. 
The back of the phalanges of the fingers are nearly 
always affected, appearing rough, uneven, and covered 
with' patches of characteristic papules. A favorite site is 
in the upper part of the internatal furrow. Some variations 
from the type are encountered in different regions, but 
characteristic types will be found somewhere on the 
body. The hair may fall, and the nails may be deformed, 
opaque, and raised by an accumulation of scales under them. 
The general condition is unaltered, and little, if any, dis- 
comfort is experienced. The duration of the disease is 
indefinite, and relapses are the rule. Second and sub- 
sequent attacks may be shorter than the first. 

Etiology. The etiology of the disease is obscure. It 
occurs at all ages, and in both sexes, but most often in 
infancy or youth, and in males. Many causes have been 
assigned to it, such as cold, excesses, rheumatism ; but none 
of these can be definitely said to be the cause. 

Diagnosis. The disease is to be diagnosed from ichthy- 
osis in not being congenital ; in attacking by preference 
the joints, scalp, face, and neck; and in its spontaneous 
recovery for a time. From dermatitis exfoliativa by its 
benign course; its location about the follicular openings ; 
and by the thick scaling of the palms and soles. From 
lichen ruber the diagnosis is difficult, the two being con- 
sidered by many as identical. H. Hebra has made a 
careful study of the two diseases, 1 and we give here his 
table of differential diagnosis between them : 

Pityriasis Rubra Pilaris. Lichen Ruber Acvmisatus. 

scales alone, which can readily 

3 »SnS limited to follicle 3. Are not limited to the follicle 

mouths, especially those of hair mouths. 

4 ExSor^urfaces of the extrem- 4. Flexor surfaces more affected than 

lengthening of the interpapil- curium, 

larv projections of the rete mu- 
cos'um in certain plao s. 

1 Monatshefte f. prakt. Dermat., 1889, x., 101. 



PITYRIASIS SIMPLEX. 437 

Pityriasis Rubra Pilaris. Lichen Ruber Acuminatus. 

6. Color of efflorescences scarcely 6. From beginning a bright red, lie- 

differs from that of the skin at coming darker, and may change 

the beginning. Afterward be- to deep rusty brown, 

comes rosy or brownish red from 
consecutive hyperemia. 

7. Roughness of the extensor surfaces 7. Everywhere thickening and 

of the extremities, and satin- roughness of the skin, incrcas- 

like smoothness on the trunk, ing with the age of the disease, 

with fine scales. 

8. No accompanying subjective 8. Unbearable itching, great burn- 

symptoms, ing, restlessness, and jerking 

movements of the limbs. 

9. No implication of the general 9. Fever, oedema (especially of lower 

health. extremities), albuminuria, 

sleeplessness, general prostra- 
tion, and loss of weight. 

10. Spontaneous recovery, or chron- 10. Often ends in death, always at- 

icity without danger to the tended with marasmus, 

patient. 

11. Cured by purely local means, 11. Cured, if at all, by constitutional 

though often obstinate. treatment, as with arsenic. 

Unna's ointment of mercury 
and carbolic acid good. 

12. Little or no pigmentation left. 12. Deep-brown, even blackish- 

brown, pigmentation left which 
may last for months. 

13. Does not affect the mucous mem- 13. Affects mucous membranes, espe- 

branes. cially of mouth and vagina. 

Psoriasis at times bears a strong resemblance to pityria- 
sis rubra pilaris, but it seeks the elbows and knees par- 
ticularly ; its scale is larger ; and it is not a follicular 
disease, never presenting comedo-like plugs, broken-off 
hairs, or little elevations. 

Treatment. No satisfactory treatment has been found, 
but the remedies applicable to psoriasis or to ichthyosis 
can be used with advantage. Like in that disease, an at- 
tack may be overcome, but no assurance can be given 
against a relapse. Thus far no fatal case has been re- 
ported. 

Pityriasis Simplex. This form of scaling of the skin is 
most often seen on the scalp, where it is spoken of as 
pityriasis capitis, and constitutes that form of dandruff in 
which there is a more or less abundant scaling of the 
scalp. The hair is dry and unmanageable, and the head 
itches, especially when the patient sits under a light or 
becomes overheated. The patient is annoyed by the con- 
stant falling of the scales upon his clothing, and if the 
disease is very pronounced brushing of the hair causes a 
small snowstorm of white, light scales. The scalp usually 
looks pale, and will be found covered with fine, grayish 



438 DISEASES OF THE SKIN. 

or yellowish, readily detachable scales. Sometimes there 
are more or less redness of the scalp and a seam of red- 
ness along the forehead. The eyebrows, bearded portion 
of the face, pubes, and other regions may be affected. 
After an indefinite time alopecia is apt to follow a pity- 
riasis. This disease is usually classed under seborrheea 
sicca. It is the slightest grade of seborrheal eczema. 
It seems to be inflammatory in its nature. The treat- 
ment is the same as that for seborrheal eczema and for 
seborrheea. 

Pityriasis Tabescentium is that condition occurring in 
marasmic individuals where there is scaling of the whole 
skin specially marked on the extensor surfaces of the 
extremities and trunk. 

Pityriasis Versicolor. See Chromophytosis. 

Plaques des Fumeurs. See Leucoplakia. 

Plica Polonica. Synonyms: Trichosis plica; Trichoma; 
(Pol.) Koltun ; (Ger.) Weichselzopf ; (Fr.) Pliqne polo- 
naise ; Polish ringworm. 

Symptoms. This is rather a condition than a disease, 
in which the hair of the head and other parts becomes 
matted together into variously shaped masses, on which 
rest all sorts of extraneous matters deposited from the air ; 
and in which are harbored vast hordes of pediculi. Some- 
times these matted tresses are near the seal]), and some- 
times far away, according to circumstances, such as the 
growth of the hair and diseases of the scalp. Not infre- 
quently an oozing eczema of the scalp will be found. 
The masses will assume all sorts of shapes, to which vari- 
ous names have been applied. An offensive odor often 
emanates from the scalp. Occurring among ignorant 
people, as is usually the case, these plicas are regarded with 
superstition. The patient and friends refuse to have them 
cut off lest some dire disease befall the bearer. 

Etiology. The cause of the condition is want of 
cleanliness combined with an oozing dermatitis of the 
scalp due to pediculi or any other cause. 

Treatment. The treatment consists in the liberal use 



POMPHOLYX. 439 

of soap and water, and curing the dermatitis. If allowed, 
the speediest way of beginning treatment is to cut off the 
hair. The patient must be instructed in the hygiene of 
the scalp. 

Podelcoma. See Fungous foot of India. 

Foils Accidentels. See Hypertrichosis. 

Polytrichia. See Hypertrichosis. 

Polyidrosis. See Hyperidrosis. 

Polypapilloma Tropicum. See Yaws. 

Pompholyx. Synonyms: Dysidrosis; Cheiro-pompholyx. 

This disease was first described by Tilbury Fox and 
Jonathan Hutchinson from the same case, though inde- 
pendently of each other. The former thought that it was 
due to distention of the sweat glands, and named it dysi- 
drosis, while the latter named it cheiro-pompholyx from 
the bullous character of the eruption and its occurrence 
upon the hands. As it occurs upon the feet as well as the 
hands, Hutchinson's name is a misnomer. 

Symptoms. The first thing that the patient notices is a 
burning and itching of the palms or soles, and sides of the 
fingers or toes. In a few hours small, clear, sago-grain- 
like vesicles, sometimes grouped, and with an erythema- 
tous zone about them, appear in these locations. They 
are often very numerous, and some of them run together 
to form small and large bullae. Their contents are at 
first clear and neutral ; later they become turbid and have 
an alkaline reaction. These vesicles do not tend to spon- 
taneous rupture. In a few days they dry up, their covers 
fall, and large and small, dry, red surfaces are left to mark 
their locations. If the lesions have been very numerous, 
the whole of the old skin may be shed. In slight cases 
the palms or soles will be dotted over with irregularly 
shaped red spots with ragged edges. As a rule, the back 
of the hands and feet are unaffected, though the rule has 
many exceptions. The patients are seldom in perfect 
health, and are usually nervously depressed. Hyperidrosis 
of the affected parts commonly accompanies or precedes 



440 DISEASES OF THE SKIN. 

the outbreak, and sometimes a lichen tropicus will be 
found on the trunk. The duration of the attack varies 
from a few days to three <>r four weeks, and relapses in 
the same or following years are common. Most all cases 
are seen in the summer. It is usually symmetrical, though 
one side may be affected before the other. 

Etiology. Over the causes of the disease there has 
been and still is active discussion. It seems to be in some 
way connected with the sweat glands, but whether it is a 
simple impediment to the escape of the sweat or an in- 
flammatory disease is not determined. Some able pathol- 
ogists ally the disease to herpes, and deny any connection 
with the sweat glands. The occurrence of the disease in 
hot weather points to the sweat apparatus as the organ at 
fault. There is probably a vasomotor neurosis at the 
bottom of the trouble. It affects all ages and both sexes, 
though most c mmion in young adult women, and in those 
who are of nervous temperament or the subjects of worry 
and over-fatigue. It is said that organic or functional 
heart disease is the cause of some cases. 

Pathology. Robinson, who has carefully studied this 
disease, regards it as a neurosis allied to herpes and pem- 
phigus. He thinks that it has nothing to do with the 
sweat glands, but that it is inflammatory. The contents of 
the vesicles, he shows, is not sweat, but serum ; and the 
reaction of the fluid is alkaline or neutral in its early 
stages, never acid. It also contains a large amount of 
albumin and some fibrin. It comes from the papillary 
blood vessels, and passing between the rete-cells collects in 
different situations in the stratum mucosura. 

Diagnosis. Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum. It 
differs from eczema in its vesicles not tending to break 
d >wn of themselves ; in not presenting a moist surface 
after the vesicle tops fall ; and in running a more definite 
course. The sago-grain-like appearance of the vesicles is 
not peculiar to it, as it is frequently seen in eczema of the 
hands, and is due to the thickness of the epithelium pre- 
venting the ready escape of the fluid. Scabies may bear 
a close resemblance to pompholyx, but can be readily dif- 



POROKERATOSIS. 441 

ferentiated by finding the burrows, and by the presence 
of the eruption at the same time upon the anterior face 
of the wrists, the breasts in women, the genitals in males, 
and about the umbilicus in both sexes. Pemphigus of the 
hands and feet is exceedingly rare in adults, and pom- 
pholyx has never been reported in infants. Moreover, 
pemphigus lacks the vesicular lesions of the sides of the 
fingers. Erythema bullosum is always on the back of the 
hands, and is not itchy, though it may burn. 

Treatment. A simple astringent ointment, as of 
oxide of zinc, or diachylon ; or one of the oleate of zinc 
or lead ; or an alkaline lotion, will allay the irritation 
and hasten the disappearance of the disease. General 
hygiene should be enforced ; and tonics of iron, arsenic, or 
whatever seems indicated by the condition of the patient, 
given. 

Porcellanfriessel. See Urticaria. 

Porcupine Disease. See Ichthyosis. 

Porrigo Contagiosa. See Impetigo contagiosa. 

Porrigo Decalvans. See Alopecia areata. 

Porrigo Favosa. See Favus. 

Poirigo Furfurans. See Trichophytosis capitis. 

Porrigo Granule. See Pediculosis. 

Porrigo Larvalis. See Impetigo. 

Porrigo Lupinosa. See Favus. 

Porokeratosis. Synonyms: Hyperkeratosis atrophica seu 
excentrica. 

Under this name Mibelli, 1 and later Respighi, 2 have re- 
ported a disease of the skin that occurs in the form of 
raised or sunken patches of various sizes and irregular 
shape, with a continuous thin, horny, linearform ridge 
about them. The skin inside of the border may be normal, 
rugous, smooth, scaly, or atrophic, while around the patches 
it may be normal, hypersemic, or pigmented. The disease 

1 Monatsliefte f. prakt. Dermat, 1893, xvii., 417. 

2 Ibid., 1894, xviii., 70. 



442 



DISEASES OF THE SKIN. 



occurs on the dorsal surface of the hands and feet, the ex- 
tensor surface of . the forearm and leg, and exceptionally 
on their flexor surface. It may also occur on the face, 
neck, and scalp, and the mucous membrane of the mouth. 
In the mouth the lesions vary from small pinhead to large 
lentil in size. They are sharply limited, with a linear 
white, opaque border enclosing an opaline area that may 




Porokeratosis. (Kespighi.) 

be raised or flattened, convex or concave, or atrophic. 
There are no subjective symptoms. Some of the lesions 
may disappear spontaneously. Generally the disease 
spreads slowly so as to occupy large areas. 

Respighi describes five distinct forms : 1. Miliary and 
submiliary papules; 2. Hemp-seed- to lentil-sized papules ; 
3. Guttate to nummular papules ; 4. Ring and circinate 



PRURIGO. 443 

disks, which is the most common form. Their edges are 
raised, regular, toothed, or zig-zag, and may be composed 
of papules arranged in chains. The disks may be round, 
oval, or elliptic ; 5. Ball-shaped lesions three to four 
millimeters high. All forms begin as papules. The dis- 
ease is bilateral and tends to symmetry. The nails may 
be affected, becoming cloudy, striped longitudinally, rough, 
thickened, raised from their bed, brittle, and they may be 
shed. 

The disease usually begins in early life, but may begin 
at any age. It is hereditary in some families. Most of 
the cases are in men. Many members of the same family 
may be affected. It consists in a hyperkeratosis of the 
sweat gland orifices, and destroys both the glands and 
hair follicles. It is thought by Mibelli to be a species of 
papilloma lineare. 

The treatment consists in destruction by electrolysis 
or in excision. 

Port-wine Mark. See Naevus. 

Post-mortem Warts. See Tuberculosis verrucosa cutis. 

Prairie Itch. This disease has been found to be in most 
cases a combination of pruritus hiemalis and scabies. It 
is not a disease sui generis. 

Prickly Heat. See Miliaria. 

Prurigo. Synonyms : Strophulus prurigineux ; Scrofu- 
lide boutonneuse benigne ; (Ger.) Juckblattern. 

A chronic disease of the skin characterized by begin- 
ning in infancy as an urticaria, and changing into a 
recurring eruption of pale, hard, exceedingly itchy, dis- 
crete papules, especially upon the extensor surfaces of the 
extremities. It increases in severity from above down- 
ward, and is accompanied by enlargement of the inguinal 
glands. 

There are two types of this disease, namely, prurigo 
mitis and prurigo ferox. These blend into each other. 
While the malady is more commonly reported from 
Vienna than elsewhere, it occurs in many countries. It is 
rare in this country, and most of the cases met with are of 



444 DISEASES OF THE SKIN. 

the mild type. The name is used by most French writers 
as synonymous with pruritus, and English writers quite 
commonly speak of " pruriginous " diseases when con- 
fusion would be avoided by using the adjective "pruritic." 

SYMPTOMS. The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak of 
urticarial wheals of various sizes and shapes. The urtica- 
rial eruption persists, but after a time a preponderance of 
small wheals will be remarked, and a preference for the 
trunk and the extensor surfaces of the limbs. During the 
second or third year the urticarial element is lost, and the 
characteristic papular eruption gradually preponderates, 
and at last takes its place. The papules are pinhead to 
hemp-seed in size, flat, firm, of the color of the skin, or of 
a bright-red, rosy, or yellowish-white color, and in many 
cases so little raised as to be felt rather than seen. "When 
the skin is irritated the papules may assume the character 
of small wheals. The efflorescences arc located principally 
upon the extensor surfaces of the limbs, and more sparsely 
on the trunk, while the seal}), the flexures of the large 
joints, the palms, soles, and genitals are free. The papules 
are not grouped. 

Pruritus is intense, so that excoriations and torn pap- 
ules are present over all the affected parts. The patients 
have a pale, weary expression of countenance, and evi- 
dently are in poor condition. The skin is often dry and it 
may be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shoAvn in the Vienna 
skin clinics. We note that the skin feels rough ; that it 
is strewn over with a great number of small papules which 
are of the color of the skin or pale red ; defaced with 
scratch-marks ; eczematous in places ; darkly pigmented, 
it may be brown, from constant irritation of the scratch- 
ing, and that the color of the general integument is in 
strong contrast with the pale color of the face; that the 
skin is thickened in some places, while the flexures of the 



PRURIGO. 445 

joints are free from change and as soft as normal ; that 
these changes in the skin are progressively worse from 
above downward, so that the legs from the knees down 
are most markedly involved ; and that the inguinal glands 
are enlarged so as to form buboes. Ecthymatous lesions 
may arise. The intensity of the itching may be so great 
as to prevent sleep, and even in some cases to drive the 
patient insane. 

The duration of the disease is indefinite; it may last a 
lifetime, but often tends to disappear with advancing 
years. The type of the disease remains the same through- 
out — that is, prurigo mitis does not change to prurigo 
ferox. 

Etiology. Prurigo affects both sexes, though it is 
more prevalent in the male sex. It is far more common 
among the poor and those who are uncleanly. It is not 
uncommon to find several members of the same family 
with the disease. A phthisical family history has been 
affirmed to be an etiological factor by some authorities. 
Some cases are better in winter and some in summer. 
It is a disease of infancy continuing through life. It 
seems to be related to urticaria. A neurosis probably is 
the underlying cause of the phenomena. Histological 
studies have not yet put the disease upon a sure anatomi- 
cal basis. 

Diagnosis. The diagnosis is made by the occurrence 
of pale papules upon the extensor aspects of the limbs ; 
by the increasing severity of the symptoms from above 
downward ; by the enlargement of the inguinal glands, 
by the peculiar look and complexion of the patient, and 
by the continuance of the disease from early infancy. It 
is differentiated from eczema by the sparing of the flexures 
of the joints ; by the presence of its characteristic pap- 
ules, and by its greater obstinacy. From papular urticaria 
it can be distinguished only by its general course. In 
fact, a doubtful case must be carefully studied over a con- 
siderable length of time before a positive diagnosis can be 
made. Scabies and pediculosis can be readily separated 
by the occurrence of the lesions on the palms, between 
the fingers, and on the genitals in the one; and the 



446 DISEASES OF THE SKIN. 

parallel scratch-marks over the shoulders in the other. 
Ichthyosis spares the flexures as does prurigo, but it is 
marked by polygonal scales, not papules ; and is free from 
the great number of excoriations found in prurigo ; it is, 
moreover, a disease that affects the whole body-surface 
more generally. 

Treatment. The disease is exceedingly obstinate to 
treatment. The patient must be put in as good a physical 
condition as possible by means of hygiene, cod-liver oil, 
iron, and a good diet. Tincture of cannabis indica is 
commended by Crocker for relief of the itching in doses 
of ten minims increased to thirty minims to a ten-year- 
old child, given three times a day directly after meals, 
and intermitted fir two weeks after every six weeks. 
These seem to me to be large doses. Simon 1 and others 
recommend pilocarpine hypodermic-ally, fifteen minims 
of a two per cent, solution once a day, for adults, or a 
corresponding quantity of jaborandi by the mouth. After 
the dose the patient is to be put in bed and covered 
with woollen blankets, where he is allowed to sweat for two 
or three hours. Carbolic acid, fifteen to twenty grains a 
day in pill, and the bromide of potassium have their 
advocates. Antipyrine and phenacetine exert a controlling 
influence over pruritus, and they are among the most valu- 
able internal remedies in prurigo. The latter, though not 
so active as the former, should be tried first in full doses, 
as it is much safer. 

External treatment is very important. Naphtol is most 
highly commended, a two to five per cent, solution, accord- 
ing to age, being rubbed in every night, and a bath of 
naphtol-sulphur soap being taken every second night. 
In older children and adults the soap treatment of Hebra, 
as described in the section on Eczema, is useful. Sulphur 
ointment used as in scabies after a daily bath ; tar used as 
in psoriasis ; a five or ten per cent, lotion of carbolic or 
salicylic acid, or the same combined with vaseline ; a five 
per cent, boric acid ointment, all have their advocates, and 
all may be tried in obstinate cases. Baths followed by 
inunctions of cod-liver oil, simple oil, tar oil, or lard, are 
1 Berlin, klin. Wochenschr., 1879, xvi., 721, 



PRURITUS CUTANEUS. 447 

often useful ; as well as baths of alum, soda, and corrosive 
sublimate. Jacquet and Tenneson report great ameliora- 
tion from wrapping the affected parts in some protective 
dressing, such as rubber sheeting or absorbent cotton. The 
spinal douche might do good in some cases. Treatment 
should be continued for weeks or months after apparent 
cure of the disease. 

The prognosis as to cure is bad, excepting in recent 
and not severe cases. These may be cured. As a rule, 
all we can do is to mitigate the patient's discomfort. Re- 
lapses are the rule. 

Pruritus Cutaneus. Itching of the skin is a symptom 
common to a great variety of dermatoses. Indeed, it has 
been said that skin diseases might be classified under two 
divisions : those that itch and those that do not itch. 
Eczema, scabies, urticaria, prurigo, pediculosis, are all 
eminently pruritic, but do not concern us here. 

Symptoms. By pruritus cutaneus we mean a func- 
tional neurosis of the skin whose only essential symptom 
is itching. This induces scratching, and scratch-marks 
are always to be found as a secondary symptom. These 
usually are in the form of scratched papules. If the 
itching is great and continuous, we will have other sec- 
ondary effects, such as thickening and pigmentation of the 
skin, and eczema of various degrees. 

The itching varies greatly in degree, from simply an 
occasional slight attack to such an intensity as to render 
the patient's life unendurable and tempt to suicide. The 
pruritus is commonly paroxysmal, but in some cases the 
pauses between the paroxysms are so short that the itching 
is practically continuous. It is almost always worse at 
night, and robs the sufferer of sleep. Changes of temper- 
ature aggravate the itching, as a rule. Very commonly 
warmth makes matters worse, and the sufferer will begin 
to scratch and keep on scratching while in the neighbor- 
hood of a fire or in bed warmly covered. He cannot resist 
the impulse to scratch, and so in bad cases he shuns society 
and becomes morbid. 

Under the general title of pruritus are often placed 



448 DISEASES OF THE SKIN. 

various parsBsthesiae, such as formication, tingling, and 
burning. 

The pruritus may be general or local. Thus we have 
pruritus universalis, a term that is rarely to be applied 
with strict accuracy, as it is seldom universal, but only 
general. In these cases the itching is now in one place and 
now in another. Bulkley, 1 by a series of observations on 
himself, strove to establish some law of reflex excitation, 
in which he was so far successful as to find that if he 
scratched one spot that itched, he relieved the sensation 
there, only to have it break out elsewhere. This general 
pruritus is most often encountered in pruritus senilis, or 
the itching of the skin of old people, and in pruritus hie- 
malis and prui'itus aestivalis, which are induced respectively 
by the cold of winter or the heat of summer. These very 
often manifest themselves on the thighs and legs only. 

Of local pruritus we have many instances. Thus we 
have pruritus ani, which afflicts both sexes, though more 
often men than women, and in which the itching extends 
to the mucous membrane of the anus. This same exten- 
sion is also seen in pruritus vulvas. This localized itching, 
with the corresponding prui'itus scroti in men, often occurs 
in connection with pruritus ani. In all these three the 
parts almost always become thickened and eczematous from 
the constant rubbing and scratching to which they are sub- 
jected, and nymphomania is sometimes a consequence of 
the itching vulva. The scalp, face, especially about the 
nose and mouth ; the palms and soles, and between the 
fingers and toes, are frequent sites of itching. More rarely 
local areas anywhere will be affected with recurring attacks 
of itching. 

Etiology. That the pruritus is due to a functional 
disturbance of the sensory nerves there is no doubt. For 
success in treatment and accuracy in prognosis it is neces- 
sary for us to endeavor to determine the cause of such 
disturbance. Hepatic derangements cause a certain pro- 
portion of eases. The intense itching of the skin in jaundice 
is evidence of this. Digestive disorders and constipation ; 
excretory disorders, as of the kidneys and skin ; albumin- 
1 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 459. 



PRURITUS CUTANEUS. 449 

uria ; lithsemia ; and diabetes, all have influence in caus- 
ing pruritus. Depressed mental states, and the disorders 
of the nervous system induced by the abuse of tobacco, 
tea, alcohol, opium, and the like, produce pruritus. Reflex 
influences from the sexual sphere and the power of imag- 
ination are responsible for some cases. In illustration of 
the latter everyone knows how many people Mall begin to 
scratch when the subject of lice is mentioned ; and how 
that long after the acarus is killed in scabies the patient 
Avill continue to complain of itching, and will not be as- 
sured that he is cured of his disease. 

In pruritus senilis the skin will be found to be atrophied 
and the fatty tissue underlying it absorbed in not a few 
cases. Pruritus ani is often due to haemorrhoids or fiss- 
ures of the mucous membrane ; or to ascarides ; or to 
the excessive use of tobacco, as well as to the causes 
enumerated above. Stricture of the urethra has been 
found to be the cause of both it and pruritus scroti. 
Pruritus vulvae is very often due to pregnancy or tumors 
of the uterus or ovaries. In this form diabetes is quite 
commonly the cause. Pruritus hiemalis begins at any 
time from October to January, and continues until the 
spring is well advanced. The effect of cold upon the skin 
seems to check the secretory functions. 

Bulkley has found pruritus to be more common in 
men than in women, fifty of his eighty cases being men. 
In some families an itching skin seems to be heredi- 
tary. 

Diagnosis. If we bear in mind that pruritus has no 
lesion of its own ; and if, whenever a patient complains 
of itching of the skin, we institute a search for the pedic- 
ulus, or the itch-mite, or their lesions ; or the wheal, or 
at least a history of it ; and find none, then we have by 
elimination gone far toward establishing a diagnosis of 
pruritus. Sometimes it is difficult to determine whether 
an eczema is secondary to the scratching for the relief of 
itching, or the itching is a partof the eczema. Only an 
attempt at curing the eczema and long observation of the 
case will enable us to make a true diagnosis. Many errors 
of diagnosis will be changed by close study, as true pruri- 

29 



450 DISEASES OE THE SKfN. 

tus is not so common as other itching diseases. Bnlkley 
found but eighty cases in 5000 private cases. 

Treatment. To find and remove the cause is the first 
essential in treating a case. How difficult this task may 
be will be seen by a study of its etiology. Nevertheless, 
the patient must be considered, and every organ interro- 
gated, and any deranged function regulated as far as 
possible. Tea, coffee, and tobacco should be interdicted; 
a dietary carefully laid down ; and the rules of hygiene, 
such as those relating to exercise, bathing, and clothing, 
enforced. To relieve the itching as such, we may give 
the tincture of cannabis indica, ten minims three times a 
day, in water after meals, and gradually increase the dose 
up to twenty or thirty minims; or the tincture of gelse- 
mium in ten-minim doses every half-hour till one drachm 
is taken or toxic effects produced ; hypodermic injections 
of pilocarpine, one-tenth to one-eighth of a grain; quinine, 
ten to fifteen grains at bedtime ; carbolic acid, one to two 
minims three times a day ; wine of antimony, five to seven 
drops after meals ; salicylate of soda, fifteen grains, or 
antipyrine or phcnacetine in full doses. Besnier recom- 
mends valerian, or valerianate of ammonium. But the 
relief so obtained is transitory, and we should not rest eon- 
tent until we have found out, and where possible removed, 
the internal underlying cause. Opium should never be 
given, as it causes pruritus. 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 
purpose general baths with soda (sviij-x to thirty gallons), 
or nitric or hydrochloric acid (sj to thirty gallons), may be 
u>v<]. After the bath the body is to be dried by wrapping 
in a warmed sheet and patting the skin dry ; then the 
skin should be smeared with vaseline and powdered with 
cornstarch from a flour-dredger. For local pruritus we 
may use lotions, of which one of the most efficient is : 

R Acid, carbol., gi-ij ; 12-25] 

Liq. potasspe, ^j ; 12 

01. lini., ad g'j; 100 

Sig. Shake before using (Bonson). I M. 



PRURITUS CUTANEUS. 451 

The patient should be cautioned to tap the skin gently with 
this, and not rub it in. So used, it will cause no damage 
and will stop the itching for hours. Carbolic acid may be 
used as a spray in the strength of half an ounce to the 
pint of water with one ounce of glycerin. To this five to 
twenty minims of oil of peppermint may be added (Hard- 
away). Alkaline lotions, as bicarbonate of soda, 3j to the 
basinful of water ; or acid lotions, such as vinegar dabbed 
on the itching spot, will often relieve. Liquor carbonis 
detergens, 3J to liv ; thymol, 3ij ; liquor potassii, sj ; 
glycerin, siij ; aquas, sviij (Crocker). Liquor picis alka- 
linus, 3j to |iv ; perchloride of mercury, gr. |-3 to 3j of 
water. All these are well attested as useful. Peroxide of 
hydrogen is highly commended by Bronson. It may be 
used as a toilet wash two or three times a day. 

For pruritus ani, scroti, et vulvae, sitting over a basin 
or pail of very hot water and sopping it up on the parts, 
followed by patting the skin dry and using a starch 
powder, will often give the patient a quiet night. If an 
eczema is present, that must first be cured. Cocaine 
lotions, as one of twenty per cent, of cocaine and five per 
cent, of glycerin ; or menthol three to ten per cent, in oil 
of sweet almonds, or of glycerin and water ; and carbolic 
acid lotions are also useful, as well as many mercurial oint- 
ments. Cocaine had best be left alone, as there is always 
danger of forming the cocaine-habit from the use of this 
seductive drug. Bulkley's antipruritic powder, of one 
drachm each of camphor and chloral, rubbed together till 
liquefied, and added to one ounce of starch powder, will 
sometimes prove very effective. Painting the parts with 
nitrate of silver, gr. xvj in spts. aetheris nitrosi fj, is 
another good proceeding. A saturated solution of boric 
acid is also good. When the parts are excoriated neither 
menthol, peppermint, nor the chloral-camphor powder can 
be used. Guaiacol, five or ten per cent, with starch 
powder, is one of the newer remedies. Suppositories con- 
taining belladonna, cocaine, or creosote may give relief in 
these cases. Of course, haemorrhoids, fissures, or other 
rectal diseases must be cured if found. 

In pruritus hiemalis it is sometimes necessary for the 



452 DISEASES OF THE SKIN. 

patient to wear linen underclothing next the skin ; and 
over it the woollens usually worn. Other patients find 
more relief from wearing silk underclothing. The treat- 
ment indicated above for pruritus is applicable here also. 

In some obstinate cases of general pruritus great ame- 
lioration may be obtained by the actual or Paquelin cau- 
tery applied lightly along the spine. The same means 
has sometimes been successful in localized pruritus, as of 
the vulva or scrotum, but now the parts themselves are 
touched with the cautery. Spinal douches are highly 
thought of by some French authorities. In these chronic 
cases it must be remembered that a cure can be effected 
with difficulty as long as the patient is exposed to the wear 
and tear of his life. Many nervous patients are well when 
travelling or living out-doors. 

Prognosis. The prognosis is doubtful. Some cases 
are very obstinate, and some are incurable. Happily, 
thorough study of the case will be rewarded in most 
cases by a cure. 

Pruritus Hiemalis. See Pruritus cutaneus. 

Pseudo-exantheme Erythemato-descmamatif. See Pity- 
riasis rosea. 

Pseudo-erysipelas. By this term is meant cellulitis or 
diffused phlegmon. 

Pseudo-leucaemia Cutis is a very rare disease. A case is 
reported by Joseph 1 as occurring in a man in previous 
good health. It commenced as a number of small glan- 
dular swellings in the neck. Shortly after their appear- 
ance severe general pruritus began to affect the patient. 
Then the inguinal and axillary glands became greatly en- 
larged, and a general eruption of hemp-seed-sized papules 
occurred. These were more easily felt than seen, and 
were of a pale-red color. The epidermis over them was 
unchanged. Wheals also appeared that changed into pap- 
ules. The skin between the papules was dark-colored, 
thickened, and dry. The case ran a chronic course, 
marked by relapses. 

1 Deutsche med. Wochenschr., 1889, p. 946. 



PSORIASIS. 453 

Pseudo-lupus. See Dermatitis blastomycotica. 
Psora. See Psoriasis. 

Psoriasis. Synonyms : Lepra ; Lepra alphos ; Alphos ; 
Psora ; (Ger.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or oval, bright-red patches covered with more or 
less thick, silvery-white, adherent scales ; by occurring 
especially upon the extensor surfaces of the elbows, knees, 
and extremities, and upon the scalp; by running a chronic 
course marked by remissions and relapses ; and by being 
more or less pruritic. 

This is one of the more common skin diseases, forming 
in this country about three per cent, of all cases. 

Symptoms. Its features of variously sized, sharply de- 
fined red papules or patches covered with more or less 
abundant silvery-white scales that occur specially upon 
the extensor surfaces of the elbows and knees, are so pro- 
nounced that the disease once seen is readily recognized 
even by the tyro. 

The primary lesion of psoriasis is always a rather 
bright-red, pinhead-sized papule covered with a dry sil- 
very-white or grayish scale. It is rare to meet with a 
case in which these small lesions are seen alone, and when 
it is, it is called psoriasis punctata. Careful search of any 
but an inveterate case will be rewarded by finding these 
lesions somewhere on the body. They soon begin to en- 
large by peripheral extension into larger patches, which 
have received various names, although all the same dis- 
ease. When they attain the diameter of about one-quarter 
of an inch, and bear a rather thick scale, they look like 
drops of mortar, and the case is then spoken of as pso- 
riasis guttata. When the lesions form coin-sized patches 
we speak of psoriasis nummularis. A single patch may 
grow to be two inches in diameter, or even larger, and 
preserve its circular shape. But the large patches are 
usually formed by the coalescence of several smaller 
patches, and may attain to a size sufficient to cover the 
greater part of a limb or even the trunk. Its circular out- 
line is now lost, and the patch has a more or less scalloped, 



454 



DISEASES OF THE SKIN. 



indented border bearing so strong a resemblance to the 
maps drawn by children that Piffard suggested the term 
psoriasis geographica for it ; but the more usual name is 
psoriasis diffusa. Alter a patch has reached a certain size 
it may elear up in the center and form a ring, and in this 
way we have psoriasis eireinata. Several of these rings 

Fig. 59. 




Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 

may meet at their circumference, when the points of con- 
taet will disappear and gyrate figures will be formed. 
When the eruption is so general as to involve the whole 
or the greater part of the body, we speak of it an psoriasis 
universalis. Not infrequently these cases bear a striking 
resemblance to dermatitis exfoliativa. 



PSOBTASrS. 455 

Every case of psoriasis does not exhibit all these varie- 
ties, because the disease may stop short at any period of 
its evolution. But in any case there is apt to be a 
number of variously sized lesions. Whatever the size of 
the patch may be, it will always be observed that the red- 
ness extends a little beyond the scales. The amount of 
the scaling will vary. Sometimes the scaling will be but 
slight ; sometimes it will be so abundant that it will heap 
up into such crust-like masses as to suggest the adjective 
rupioide. The scales are constantly being shed, and as 
constantly renewed. They may be readily scraped off 
with the nail ; and if this is carefully done, a delicate glis- 
tening membrane will be exposed, under which will appear 
dot-like red points. That is, we have removed the epi- 
dermis and exposed the mucous layer of the skin, the red 
points being the tops of the slings of blood vessels of the 
papillae. This is thought by some to be characteristic of 
psoriasis, but with care it may be produced in other 
diseases. 

The color of the scales is silvery white or grayish. 
Darker scales are due either to the deposition of dust or 
the admixture of blood. The color of the patch will vary 
from a pinkish red. to a dark red, the darker color being 
seen upon the legs, where the color of all lesions is darker 
on account of the partial stasis in the return flow of blood. 
The disease is always a dry one, there being absolutely 
no discharge feature in its course. The patches are sharply 
defined, but so little raised that they can be nearly all 
scratched away. 

AVhile psoriasis may occur anywhere on the body, and, 
as we have seen, may become universal, its most frequent 
locations are the extensor surfaces of .the limbs, elbows, and 
knees, or rather the face of the tibia? just below the knee, 
and the scalp. It may occur upon the first two locations 
alone. When it occurs on the scalp careful examination 
will generally show some lesion elsewhere on the body, and 
we will usually find a little patch in front of the ears, and 
very often there will be a red scaly line on the forehead 
just in front of the hair-line, a feature that is as striking 
and as characteristic of psoriasis as the corona veneris is 



456 



DISEASES OF THE SKIX. 



of syphilis. The hair does not fall, as a rule. In some 
cases, however, we may have transient or permanent 
alopecia. The whole scalp may be covered with a con- 
tinuous patch, or distinct scaly patches may form as on the 
body. In any event the border of the patch will be 
sharply defined. 

Fig. GO. 




Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 



The palms and soles arc very rarely the seat of the dis- 
ease, and then only ns part of general psoriasis. It is 
true that a few eases have been reported in which it lias 
been said even to be located upon one hand alone, and this 
by competent observers; but the probabilities are all in 
favor of such cases having been either syphilis, which 



PSORIASIS. 457 

is most likely, or squamous eczema. The disease is 
bilateral, and sometimes may show a decided tendency to 
symmetry. 

In old, inveterate cases there may be considerable thick- 
ening of the skin, a feature that is usually wanting, and 
fissures may form about the joints that may be painful and 
bleed. This may also occur on the scrotum, or on the trunk 
where the skin is in folds. 

The nails are affected in some cases, becoming opaque, 
lusterless, furrowed transversely, discolored, and some- 
times cracked ; while they are raised from their beds by 
the accumulation of scales underneath them. All the nails 
are rarely diseased at the same time ; usually it is but one 
or two nails on each hand or foot. Sometimes the disease 
is limited to a strip along the side of one nail. 

There is no constitutional disturbance in this disease, 
the patients usually being in as good health as the majority 
of mankind. Sometimes they have pains in the joints 
that are regarded as rheumatic by some, and as neurotic 
by others. Itching is very often an annoying symptom. 
Sometimes it is entirely wanting. 

The course of the disease is variable. Although it is 
always chronic, it presents at times acute symptoms. 
Relapses are the rule, to which there are few exceptions. 
In some cases the skin will be entirely free from all trace 
of the disease for months or years. In most cases this 
freedom is only partial ; even though the patient thinks he 
is clean, some little spot will be discoverable. The dura- 
tion of each patch is also variable. It may disappear in a 
few weeks or remain for months. Most cases are better 
in summer, to become worse in winter. When the patches 
disappear, they do so completely, though a slight amount of 
scaling may be present for a short time. In a few very 
rare cases a chronic psoriatic patch has become papillo- 
matous and then epitheliomatous. 

Etiology. Various theories have been advanced in 
the etiology of psoriasis, and some facts have been estab- 
lished by our study. We know that the disease is hered- 
itary in a number of cases. Greenough l found the pro- 
1 Boston Med. and Surg. Journ., 1885, cxiii., 163. 



458 DISEASES OF THE SKIN. 

portion as high as one-third. It may occur at any age 
Kaposi has reported a case at eight months of age, and 
Riehl ' one at thirty-eight days. It usually is a disease 
of early adult life, making its first appearance before the 
thirtieth year. It is rare after the fiftieth year. It 
affects both sexes and all conditions of life. These things 
we know. 

While the majority of patients seem to he in the best 
of health, some are rheumatic or gouty. In some cases 
there will be an unusual amount of indican in the urine. 
A lowered condition of the general health seems, in some 
cases, to favor an outbreak either of a primary attack or of 
a relapse. Thus it is no uncommon thing to see thedisease 
in women grow worse during pregnancy or lactation. 
Malassimilation or digestive disorders also seem to aggra- 
vate or provoke the disease, Hardaway even affirming that 
he has known the inordinate eating of oatmeal to cause 
thedisease, while Gowers 2 reports cases produced by the 
ingestion of borax as a medicine. Polotebnoff 3 has written 
an elaborate thesis to show that the disease is a vasomotor 
neurosis, affirming that in a majority of cases there will 
be found evidences of either trophic or vasomotor disturb- 
ance-, or a history of more or less profound nervous 
troubles either in the patient or his family. A number 
of cases following fright or nerve-shock have been re- 
ported. In the Vierteljahr. f. Derm. v. Syph. for 1878, 
Lang brought out his parasitic theory, and in No. 208 of 
Volkmann's Sammlung Min. Vortrdge the thesis is further 
elaborated, the fungus being represented by illustrations. 
He has found some support from other observers, but the 
theory has not gained general credence. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the location 
of a patch of psoriasis. 

Pathology. Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 

1 Mnnntxhefte f. prakt. Dermat., 1S9-3, xxi., '28.°,. 

2 Lancet. October 24, 1884. 

s Monatshefte f. Drakt. Dermat, 1891, Lrganzungsheft, No. 1. 



PSORIASIS. 459 

keratolysis, or an anomaly of cornification in which an 
in] perfect corneous layer is formed. Some teach that the 
process begins in the rete, and the changes in the corium 
are secondary ; while others hold the reverse view. Lang 
names his parasite epidermidophyton, and describes it as 
composed of mycelia and spores, either disseminated or in 
groups, which are so delicate as to be seen only with very 
high powers. 

Diagnosis. A typical case of psoriasis presenting 
round or oval, variously sized, pinkish-red, dry patches 
covered with thick silvery-white scales, scattered more or 
less generally over the body, but showing a marked 
preference for the extensor surfaces of the extremities, and 
especially of the elbows and knees, is readily recognized. 
In some less typical cases it needs to be differentiated from 
syphilis, eczema, seborrhoea, dermatitis exfoliativa, lichen 
ruber, and lichen planus, seborrhoeal eczema, and possibly 
from lupus erythematosus. From the ptapulo-squamous 
syphilide of the secondary stage of the disease it differs 
by showing preference for the extensor surfaces of the 
limbs and the posterior surface of the trunk, though there 
are many exceptions to this rule. The syphilide is not so 
scaly ; its red is darker, more raw-ham-colored ; the lesions 
are more infiltrated, giving a more shotty feeling to the 
finger ; they do not itch ; they run a more acute course, 
and are of more uniform size, never exhibiting the patchy 
character of psoriasis. It is usually easy to establish the 
presence of other manifestations of syphilis, such as sore- 
throat, pains in the bones, fall of the hair, and per- 
haps the remains of the initial lesion. The late scaly 
syphilide is never general ; is un symmetrical, usually 
consisting of one or two groups of lesions that show no 
tendency to affect the elbows and knees. The lesions are 
more raised and prone to leave scars. There will also be 
the history of past syphilicles to guide us, and an absence 
of those relapses so common and characteristic of psoriasis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is ; the patch is more infiltrated ; the scaling is 
less, the scales being thinner ; exudation can be readily 
induced ; and a history of moisture at some time will be 



460 DISEASES OF THE SKIN. 

found. The patch of eczema is generally less sharply 
defined, and is more apt to shade off into* the surround- 
ing skin. If the scales of a psoriatic patch are removed, 
a delicate membrane is left showing red dots — the tops 
of the blood vessel slings in the papillae ; if the same thing 
is done in eczema, a discharging surface will be left. 

Seborrhcea may simulate a psoriasis when it occurs in 
patches on the chest or as thick crusts on the scalp. The 
patches on the chest have a more yellow color and their 
scales a more 1 greasy feel than is the case in psoriasis. On 
the scalp the crusting of seborrhcea does not occur in such 
sharply defined patches, and its crusts are very greasy. 
In either case, if it be one of psoriasis, we will be sure to 
find one or more typical lesions somewhere on the trunk. 

It is cpiite impossible to differentiate a true case of der- 
matitis exfoliativa at first sight from one of general pso- 
riasis. If it does arise from psoriasis, there will be a 
history of its gradual spread from typical lesions, quite 
different from what obtains in true dermatitis exfoliativa, 
which is more rapid in its evolution. Psoriasis is rarely 
so absolutely universal as is dermatitis exfoliativa. Watch- 
ing the case for a time will establish the diagnosis. If 
psoriasis is the malady, it will declare itself after a time 
by the diffused redness clearing up and typical psoriatic. 
patches showing themselves. 

IAchen ruber presents small, pointed papules upon the 
trunk at first, and not the large scaling papules upon the 
extensor surfaces of the limbs of psoriasis. When the 
disease becomes general we will have the history of these 
lesions, and the skin will be more thickened and rugose. 

Lichen planus occur- by preference on the flexor rather 
than the extensor aspects of the limbs, and in the form of 
flat, shining, angular, smooth papules, rather than of 
round, freely scaly ones. The color of its patches is viola- 
ceous and not bright red. If it becomes universal, it 
does so evidently by the springing up of new small lesions 
between the old ones, and not by the peripheral growth 
and coalescence of those already existing. The thicken- 
ing of the skin is also much greater than in psoriasis. 

In the diagnosis from seborrhcea/ eczema Unna lays great 



PSORIASIS. 461 

stress upon four points: 1. Seborrhoeal eczema spreads 
from above downward, mostly in the middle line of the 
body, and its lesions are quite stationary in character; 
while psoriasis begins on the elbows and knees, and more 
speedily affects the whole body. 2. There is always a 
history of a seborrhoeal affection of the scalp in seborrhoeal 
eczema. 3. The scales of seborrhoeal eczema are fatty 
and crumbling, and the patches are yellowish ; in psoriasis 
the scales are white and friable, not greasy, and the patches 
are bright red. 4. The proneness of the patches of sebor- 
rhoeal eczema to form bow-shaped figures, or rings more or 
less broken. Psoriasis may be circinate, but the margins 
of the figures are not so narrow and not follicular as they 
may be in seborrhoeal eczema. 

Treatment. Though external treatment alone will 
remove the evidences of psoriasis upon the skin, producing 
a cure of the disease — if that may be said of a disease that 
is almost sure to relapse — we generally can procure more 
prompt results by a combination of internal and external 
remedies. The first inquiry in all cases should be made 
as to the general condition of the patient, and we should 
endeavor to establish in him as perfect a state of health as 
is possible. A restricted diet certainly does have a good 
deal of influence in causing an amelioration of the disease. 
No hard-and-fast lines can be set in this respect. In the 
service of Prof. George Henry Fox, who is a strong advo- 
cate of dieting in skin diseases, I have seen some patients 
improve under a strictly vegetable diet, and others do 
equally well on a dietary composed largely of milk and 
animal food. A stout, evidently overfed, plethoric patient 
will be benefited by cutting off all, or nearly all, meat. 
In this class of patients it is a good plan to insist upon a 
milk diet for a few days. An anaemic, underfed patient 
will, on the other hand, improve under a more liberal 
dietary. Alcoholics, and especially malt liquors, should 
be interdicted in all cases, as well as rich gravies and 
highly spiced foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 



462 DISEASES OF THE SKIN. 

tion as remedies for psoriasis, though it must be confessed 
that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most gen- 
eral practitioners as the remedy for psoriasis. It does do 
good in this disease, but at the same time it is not to be 
considered as a true specific. In acute cases it aggravates 
the disease and should never be given. In chronic cases 
that have proved very stubborn it may be tried, and some- 
times it will produce a speedy cure. The vast majority 
of cases will do quite as well without it. It may be given 
in the form of Fowler's solution with or without the wine 
of iron, and administered in water three times a day after 
meals. The initial dose for an adult should be about 
three drops, and the amount should be gradually increased 
until the limit of toleration is reached. Crocker thinks 
that the efficiency of this form of arsenic is enhanced by 
the addition of half a drachm of the tincture of lupulus to 
each dose. The Asiatic pill is the favorite mode of using 
arsenic in Vienna. It is composed, according to Kaposi, 
of— 

R 



Pulv. ao. arseniosi, 


gr- xj ; 






75 


Pulv. piperis nigrse, 


giss ; 




6 




Gummi acacire, 


gr. xxij ; 




] 


50 


Pulv. altlia?. rad., 


gr. xxx ; 




2 




Aqna>, 


q. s. ; 


q 


s. M 


Div. in pil. No. c. 











One pill is given after meals, and the dose is increased 
gradually every four or five days until ten or twelve are 
taken a day, unless some constitutional disturbance is 
caused before then. The method of increase is by first 
giving one pill after each meal; then two pills after break- 
fast, and one after the other two meals; and then two after 
breakfast, two after the midday meal, and one in the even- 
ing, and so on. Or we may make use of the tablet trit- 
urates of arsenious acid with piperina, giving those con- 
taining one-twentieth of a grain of the arsenic in the same 
manner as the Asiatic pills. Any other preparation of 
arsenic may be used. Hypodermic injections of arsenic 
have been employed with success, but it would be hard to 
induce an American patient to endure this method. The 



PSORIASIS. 46Z 

administration of the drug must be persisted in for a long 
time, and it may prove curative by itself. 

Alkalies that act as diuretics are often very helpful, 
quite apart from any indication for their use on account 
of gout or rheumatism. A beginning psoriasis, or even a 
case of some duration, will be favorably influenced by the 
administration of the acetate or citrate of potassium in 
fifteen-grain doses before meals, well diluted, and followed 
by drinking half a glass of water. The undoubted efficacy 
of large doses of the iodide of potassium, as recommended 
by Haslund, 1 may depend, in part at least, upon its diu- 
retic action. He gives the salt in increasing closes, so that 
as much as six hundred grains have been administered to 
one patient during the day. AVhen assistant physician to 
the New York Skin and Cancer Hospital, in Dr. G. H. 
Fox's division, I tried Haslund's plan in several cases. 
They certainly were greatly benefited. The objections to 
this method are the expense of the drug and the danger of 
the sudden production of poisoning, shown by palpitation 
of the heart, severe headache, and faintness, and necessi- 
tating either the keeping of the patient in a hospital or 
under the constant attendance of a physician. 

Turpentine oil is highly commended by Crocker as fol- 
lows : It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 
dose is ten minims three times a day after meals. It may 
be increased by five or ten minims at a dose until the 
patient, if tolerant of it, is taking thirty minims three times 
a day. Barley-water must be freely drunk during the 
day to prevent any bad effect on the kidneys, and the 
last dose of the turpentine should be taken not later than 
six or seven o'clock in the evening. Dyspepsia and irri- 
tability of the urinary organs contraindicate its use. The 
same authority advocates the use of salicylate of soda in 
fifteen-grain doses three times a day after meals, or salicin. 

The wine of antimony in five- to ten-minim doses is 

recommended by Mr. Malcolm Morris as efficacious in 

acute cases. Hyde speaks well of the protiodide of mercury, 

one-fifth grain three times a day. I have seen benefit in 

1 Vierteljahr. f. Derm., u. Sjph., 1887, xiv., 677. 



464 DISEASES OF THE SKIN. 

some cases from the use of intestinal antiseptics, such as 
salicylic acid and salol. 

Chrysarobin by the mouth, one-sixth of a grain in sugar 
of milk three times a day, and increased to one or two 
grains at a dose, acts well in some cases, but is very apt 
to cause so much nausea and vomiting as to compel its 
discontinuance. 

Polotebnoff, believing the disease to be a neurosis, ad- 
vocates the use of bromide of potassium and of ergot. 

As most patients are worse in winter than they are in 
summer, when the skin is more moist from active perspi- 
ration, a residence in a mild climate might well be com- 
mended to a chronic psoriatic. 

External treatment. Before making any application to 
the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with 
simple oil, or vaseline, combined with attention to diet, 
will produce a cure. These measures should be tried first 
in all newly beginning cases. In some cases there will 
be well-marked eczematous conditions. Then we must 
use remedies applicable to that disease. Generally we 
must resort to more stimulating remedies. The most 
useful and most promptly curative external remedy is 
chrysarobin (ehrysophanic acid). The objections to it 
are its tendency to produce an acute dermatitis and its 
permanent staining of everything with which it comes in 
contact. These unpleasant effects may be in part over- 
come by combining the drug with flexible collodion or 
traumaticin, but only in part. The dermatitis is always 
most marked upon those parts in which there is laxity of 
the skin, and if it is used on the face it is prone to produce 
great swelling about the eves. Care must be taken not to 
get it in the eyes, as it causes violent conjunctivitis. These 
effects should make us very cautious about using it on the 
scalp, and prevent its use on the face. 

The most active form in which to use the drug is in an 
ointment, as of lard, lanolin, or vaseline. Gelanthum, 
and plasment are excipients that have the merit of not 
being greasy, and of being readily and entirely removed 



PSORIASIS. 465 

by means of water. Flexible collodion and traumaticin 
(liquor gutta-perchse) are good excipients. 

The strength of chrysarobin should not exceed one 
drachm to the ounce, as a rule ; though in exceptional cases 
it may be used in greater strength. Its activity is in- 
creased by the addition of salicylic acid (three per cent.), 
and then it is best to use it in a lower percentage, even five 
per cent, being active enough. An alkaline bath before 
using the chrysarobin increases its potency. If we use an 
ointment, it should be thoroughly rubbed in once a day 
after the scales are removed. If the vehicle is gelanthum, 
plasment, collodion, or gutta-percha solution, the spots 
should be painted over as often as the film left by the ap- 
plication falls. The patient should always be warned 
against getting the drug in his eyes. A favorite formula 
of Dr. George H. Fox is the following : 

Ac. carbolici, 1 part. 

Ac. oleic, 50 parts. — M. 

If the chrysarobin produces too great a reaction, it 
must be stopped, and the skin treated with vaseline and 
starch powder, or an alkaline wash. The action of the 
drug upon the skin is peculiar. It stains the skin about 
the patches a mahogany red, Avhile the patches become 
smooth and white. It discolors the nails and the hair, but 
after a time the staining disappears. Not so the staining 
of the clothing, which is permanent. It is said that it can 
be somewhat lessened by soaking the clothes in plain water 
before using soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. It 
is still a reliable remedy, but it cannot be used over the 
whole body in a general psoriasis on account of the danger 
of absorption of the mercury. It is the pleasantest and 
promptest application to the scalp and face, and can be 
used there while chrysarobin is used on the rest of the 
body. An ointment of 



466 DISEASES OF THE SKIN. 

33 



Hydrarg. amnion., 


gr. xx ; 


1 


Hydrarg. chlor. mitis, 


gr. xl ; 


2 


Petrolati 


ad sj ; 


ad 32 



M. 

is sometimes better than that of the ammoniate by itself. 
Other mercurial ointments, such as that of the yellow 
oxide, and a dilute ointment of the nitrate, may be used. 
Lang has found the bichloride of mercury in collodion in 
one-fourth to one-half per cent, strength a good applica- 
tion. It would probably be an unsafe one in a case of 
any extent. 

Tar is another old and reliable remedy, still much used 
in France. It may be employed in an ointment, or oil, 
or dissolved in alcohol. The oil of cade, oil of birch, or 
pure tar may be used in the strength of half a drachm to 
four drachms to the ounce. In Paris the following is 
sometimes used : 

R Glycerol, amyli, | ~ 100 ts> 

Ol. cadini, J r 

Sapo. viridis, 5 " M. 

This is to be rubbed in at night ; the patient is to sleep in 
a flannel gown, and wash the ointment off in the morning. 
Kaposi recommends the following : 

K 01. rusci, 50 parts. 

^Etheris sulphuris, "1 -^ 75 « 

Aleoholis, J 

Filter and adde 

01. lavandulae, 2 " M. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symp- 
toms. 

Pyrogallol (pyrogallic acid) is efficacious, but can be 
used" only in cases in which the eruption is not exten- 
sive, on account of its poisonous action when absorbed. 
It may be used in the strength of about ten per cent, in 
ointment. It stains the skin, but causes less inflamma- 
tory reaction than chrysarobin does. 

Thymol was introduced by Crocker. It may be used 



PSORIASIS. 467 

as an ointment or lotion in the strength of fifteen grains 
to three drachms to the ounce. As it is colorless and of 
pleasant odor it is suitable for use on the face. The same 
authority advocates the use of turpentine locally. He uses 
the oleum pini sylvestris with sufficient oil of lavender or 
essence of lemon to mask its odor. If used undiluted, the 
skin must be smeared with vaseline to prevent its crack- 
ing. It is better to use it diluted with olive oil, 3J of oil 
of turpentine to 3vij of olive oil, the proportion of the oil 
of turpentine being increased as the skin becomes accus- 
tomed to it. The addition of oil of cade or oleum rusci to 
the mixture increases its efficacy. 

Salicylic acid, five to twenty per cent, strength, will 
remove the scales, and in some cases will prove curative. 
The soap treatment, as described under chronic eczema, is 
of great value in some chronic circumscribed cases. Sul- 
phur ointment, oleate of copper, " rufigallic " acid, ten per 
cent, in ointment, and resorcin, have all done well in some 
cases. Hydracetine, anthrarobin, and aristol are among 
the latest remedies, but have not proved themselves as 
active as some of the older ones. 

Gallacetophenone in five to ten per cent, strength as an 
ointment or dissolved in collodion may be tried, but is not 
as good as chrysarobin. 

Some patients have found benefit from the use of 
natural mineral waters at spas. It is possible that much 
of the benefit so obtained is from the prolonged and 
regulated bathing. Wearing rubber clothing next the 
skin, or with a fine piece of muslin between the rubber and 
the skin to avoid the production of eczema by the rubber, 
will soften and remove the scales, and hasten the dis- 
appearance of the patches. 

Prognosis. 'A cure of psoriasis may be promised with 
a fair degree of certainty as far as the removal of the erup- 
tion then out is concerned ; but no promise can be 
made that the disease will not relapse. In this respect 
psoriasis resembles rheumatism and gout. While most 
relapses are readily removed in the course of a few weeks, 
in some cases one or more patches will be remarkably 
obstinate. 



468 DISEASES OF THE SKIN. 

Psorospermosis Follicularis Cutis is the name given by 
French writers, notably by Darier, 1 to a disease of the 
skin, casts of which had previously been reported under 
the names of lichen spinulosum (Hutchinson), ichthyosis 
sebacea cornea (Wilson), acne sebacea cornea (Guibout), 
ichthyosis follicularis (Lesser), keratosis follicularis (Mor- 
row and White), acne cornee (Leloir and Yidal), caco- 
trophia folliculorum (T. Fox), and sauroderma. The title 
psorospermosis was given by Darier in the erroneous belief 
that he had found certain parasites belonging to the order 
of protozoa, which have been named psorosperms, in causal 
connection with the disease These have been demon- 
strated to be only changed epithelial cells. (For descrip- 
tion of the disease see Keratosis follicularis.) 

Pterygium is simply an overgrowth of the normal nail- 
fold at the proximal end of the nail, so that it covers to a 
greater or less extent the lunula. It may be cut off. 

Purpura. Synonyms : Hsemorrhcea petechialis ; (Ger.) 
Blutfleckenkrankhe.it. 

Symptoms. By this term is meant a hemorrhage into 
the skin which is not caused by direct traumatism. It is 
always readily recognized by the red, purple, or blue- 
black color that it causes, which cannot be made to dis- 
appear by pressure. The hemorrhage may take place 
into any part of the skin ; into the subcutaneous tissues ; 
or into any of the glandular apparatus of the skin. It 
occurs with suddenness, and produces variously sized 
lesions to which certain names have been applied. When 
they are small, from pin-point size to perhaps an inch in 
diameter, they are called petechia:. When occurring in 
the form of more or less long streaks they are called 
v ibices. Large bruise-like lesions with more or less swell- 
ing are ecchymoses. Blood tumors of all sizes are ec'ehy- 
momata or hoBmatcmiata. The color of all purpuric lesions 
depends upon their age. When first formed they are 
bright red, claret, or purple. Before disappearing they 
pass through various shades of color such as are seen after 
an ordinary bruise, becoming blue black, greenish black, 
1 Ann. dv derm, et de syph., 1889, x., 597. 



PURPURA. 469 

or brownish. These changes are cine to the gradual 
absorption of the effused blood and the hsematin deposited 
from the blood globules. There is no definite time for 
complete absorption to take place, but eventually no trace 
is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair 
follicles, we will have papules formed. If between the 
layers of the epidermis, hemorrhagic bullae may result. 
Hemorrhage into sweat glands will give rise to haemati- 
drosis. As complications of other dermatoses hemorrhage 
may occur, as in urticaria, pemphigus, and eruptive fevers, 
but these should not be elevated into special varieties of 
purpura. 

There are three varieties of purpura, namely, purpura 
simplex, purpura hemorrhagica, and purpura rheumatica. 
It is convenient for us to preserve these varieties for a 
time, though the results of the latest studies seem to indi- 
cate that the second variety is but a more developed form 
of the first, cases of simple purpura having been seen to 
run into the hemorrhagic form. By Crocker and others 
the third variety is regarded as a form of erythema 
exudativum. It, too, has been seen to riua into the 
hemorrhagic form . 

Purpura Simplex is the most common variety, and 
usually takes the form of petechia 3 , the lesions being 
round or oval, or irregular in shape, or even circinate. 
Duhring describes a case of the circinate form, as does 
Stelwagon. 1 The lesions appear suddenly, generally with- 
out antecedent symptoms, and often at night. Like other 
varieties of purpura, the lower extremities are the most 
common seat of the eruption, especially their flexor aspects, 
but any part of the skin may be attacked, as also the 
mucous membranes. Crocker affirms that in children the 
lesions appear first upon the neck and upper part of the 
back. The lesions appear in crops, and most often are 
symmetrical. There may be but a single outbreak, and the 
whole disease may be at an end in a week or two. But 
it may be prolonged for many weeks by a succession of 
outbreaks. There is usually no constitutional disturb- 
1 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 369. 



470 DISEASES OF THE SKIN. 

ance, or a slight rise of temperature and malaise, and 
the only things the patient complains of are the spots, and 
perhaps some itching. There may be lassitude, malaise, 
and slight elevation of temperature. Recovery is the rule. 
Exceptionally purpura simplex passes over into 

Purpura Homtorrhagica. This form is also called mor- 
bus macvlosus Werlhoffii and land scurvy. It usually 
begins as such, and is heralded by pronounced malaise, 
rise of temperature, headache, and perhaps convulsions. 
It begins without prodromata. It differs from the pre- 
vious variety in the more extensive hemorrhages that 
take place, ecchymoses forming rather than petechia?, and 
in free bleeding from all the mucous membranes — nose, 
mouth, stomach, urethra, rectum, vagina. These are so 
copious and uncontrollable at times that the patient will 
literally bleed to death in a few hours. Sudden death 
may also be caused by hemorrhage into the meninges and 
brain. An excellent study of this fulminating form of 
purpura has been made by Lockwood. 1 In his case there 
was a rise of temperature to 106.2° F. just before death, 
and the patient died in about sixty hours from the onset 
of the disease. He collected thirty cases, in thirteen of 
which the patients died from acute anaemia, internal 
hemorrhages, or septic infection, the shortest duration 
of any one case being seven hours ; in eight cases death 
was due to cerebral hemorrhage ; and in four cases 
the patients were pregnant. Happily all cases of hemor- 
rhagic purpura are not fatal. In them the bleeding is 
moderate in amount, and the patient is gradually restored 
to health. Relapses may occur. 

Purpura Fulminans is the name applied to those very 
grave cases of purpura in which the patient dies in a short 
time. It is a form of purpura hemorrhagica. It may 
affect several members of the same family, which suggests 
its infectious nature. It has followed scarlatina. 

Purpura RheumaHca. This is also called peliosis rhcu- 
matica. It resembles purpura simplex in every way, ex- 
cepting that the outbreak of the eruption is preceded or 
followed by pain in the joints accompanied by swelling, 
»Med. Rec, 1891, xxxix., 155. 



PURPURA. All 

the malaise is more marked, and there is often rise of tem- 
perature. The eruption is often most abundant about the 
joints. The aeute symptoms subside in two or three days, 
but relapses are frequent. True rheumatism may be pres- 
ent at the same time. Valvular heart lesions have been 
reported to occur after this variety of purpura, even with- 
out true rheumatism. Rarely this variety may pass over 
into the hemorrhagic form. 

Etiology. Many causes have been assigned to ac- 
count for the occurrence of purpura. We know that it 
may occur at any period of life, in both sexes, and in the 
most varying conditions of health. We meet with cases 
in the spring and autumn, in weather that is damp and 
cold. There is no doubt that purpura occurs as a symp- 
tom in different diseases and cachexia ; after the ingestion 
of certain drugs, and under other circumstances too 
numerous to catalogue here. Here we can readily sur- 
mise that one or both of two things have occurred, 
namely, a change of the blood itself that allows of its 
passing through the walls of the vessels or a change in 
the vessel walls themselves that permits the blood to 
pass through them. Purpura has been noted after the 
loosening of some artificial support to a part of the body, 
such as a tight bandage worn for a long time. It occurs 
not infrequently in old age. In both these conditions it 
is due to a weakening of the tone of the vessel. In the 
former case matters right themselves in a few days — a 
happy conclusion that cannot be anticipated in the latter 
case. Weakness of vascular walls may also be the cause 
of those somewhat rare cases of purpura without cachexia 
seen in infants. Other cases of purpura are due to small 
thrombi lodging in the smaller vessels. Some cases seem 
to be due to vasomotor or trophic nerve action causing 
either sudden alterations in the caliber of the vessels or 
degenerations in their walls. Recurring purpura has 
been noted about the point of greatest pain in neu- 
ralgia. 

The microbial! and infectious origin of purpura has its 
advocates. Some authorities believe that purpura occur- 
ring in an infectious disease is due to micro-organisms. 



472 DISEASES OF THE SKIN. 

Letzerich 1 published a brochure on this subject in 1889, 
in which he described the "bacillus purpurse haemor- 
rhagicae Letzerich " as the cause of the disease. This has 
sharp angles and edges, is readily cultivable, and pure 
cultures injected into rabbits give rise to hemorrhages 
either spontaneously or on slight trauma. 

PATHOLOGY. It is in the curium that the hemorrhages 
chiefly occur, but the subcutaneous tissues are sometimes 
implicated. Examination of the blood shows irregular 
changes in the number of blood cells and in their form, as 
well as in the quantity of fibrin. 

Diagnosis. The diagnosis of purpura is easily made. 
No other disease produces bright-red, slightly elevated 
lesions, the color of which cannot be made to disappear 
under pressure. From flea-bites they are distinguishable 
by the absence of a central punctum. Purpura hemor- 
rhagica bears a close resemblance to scui'vy, but in the 
latter a dietary deficient in vegetables is a marked etio- 
logical factor ; there are also greater prostration, swelling 
of the gums, loosening of teeth, and brawny swelling 
of the limbs. It is possible that further investigations of 
scurvy may show that it is but a form of purpura hemor- 
rhagica that has been modified by diet. 

Treatment. In simple purpura there is not much to 
be done except to put the patient in as good a hygienic 
condition as possible and relieve symptoms. In peliosis 
rheumatica and purpura hsemorrhagica the patient should 
be kept absolutely quiet in bed, his diet should be of the 
most nutritious and easily assimilable kind, and ergot and 
iron administered. Of course, if there is hemorrhage 
from the nose, vagina, or other mucous cavity, an effort 
must be made to -top the flow by means of a tampon, ice, 
hot water, or any method that experience has proved use- 
ful. Ergotine may be employed hypodermically ; and 
turpentine; dilute sulphuric acid; nitrate of silver in pill- 
form, one-eighth to one-sixth of a grain three times a day ; 
and other astringents have been found useful. Letzerich 
recommends for the local treatment of bleeding from the 
gums — 

1 Monatshefte f. prakt. Dermat., 1889, ix., 312. 



PUSTULA MALIGNA. 473 

R Tinct. ratanhige, 10 parts 

Tinct. iodini, 5 " M. 

of which ten drops are to be taken in a wineglassful of 
water. For this purpose other astringents, as tannin, 
alum, and the like, may be used. 

Prognosis. From the beginning of a case it is not 
possible to say how it will turn out. We should there- 
fore be very guarded in our prognosis. Most cases met 
with terminate favorably. Some apparently desperate 
cases recover. 

Pustula Maligna. Synonyms : Anthrax ; Malignant 
pustule ; (Fr.) Charbon. 

This is a disease of cattle, sheep, and horses, in which 
it is called splenic fever, and is due to local inoculation 
with the bacillus anthrax, often through the agency of 
flies. If the bacillus gains access to the internal organism, 
it produces a rapidly fatal general disease with no skin 
lesion. In the human the exposed parts — face, hands, 
and neck — are the most frequent sites of the disease. 
In a day or two after inoculation the patient notices 
a burning or itching of the affected part and the formation 
of a livid-red papule upon which a bulla or pustule soon 
forms. This ruptures, the red spot changes into a black 
gangrenous eschar, the parts around it become indurated, 
oedematous, of dusky-red hue, and studded with small 
vesicles or pustules. There are marked involvement of 
the lymphatics and enlargement of the neighboring glands, 
that may suppurate. In favorable cases the slough sep- 
arates and healing by granulation takes place. In fatal 
cases the gangrenous process extends rapidly, symptoms 
of septic infection declare themselves, and the patient suc- 
cumbs to the disease in from two to eight days. In all 
cases there is more or less constitutional disturbance. 

Diagnosis. The diagnosis of malignant pustule is 
made mainly by the rapidity with which the disease 
develops ; the presence of the gangrenous patch with the 
hard indurated tissues about it ; and the severity of the 
constitutional symptoms. The finding of the bacillus will 
verify the diagnosis. 



471 DISEASES OF THE SKIN. 

Treatment. The total excision of the diseased patch 
by means of a free incision is the most radical and effec- 
tual treatment for the disease. The injection of iodine or 
of a five per cent, solution of carbolic acid under the eschar 
is a good method of treatment. The hyposulphite or 
sulphite of soda, and large doses of quinine, are worthy 
of trial. 

Quinquaud's Disease. See Folliculitis decalvans. 

Radesyge. See Lepra. 

Raynaud's Disease. See Dermatitis gangrenosa. 

Red Gum. "An obsolete term for various transitory 
eruptions in teething children." (Foster.) Commonly 
this is miliaria rubra. 

Rhinophyma is the term used to designate that form of 
hypertrophic rosacea in which pendulous tumors develop 
on the nose. These may attain so great a size that they 
hang down over the mouth. Sec under Rosacea. 

Rhinoscleroma. Synonyms : (Fr.) Rhinosclerome ; (Ital.) 
Rinoscleroma ; Perisarcoma. 

Symptoms. This is an exceedingly rare form of dis- 
ease that was first described by Hebra and Kaposi. It 
affects almost exclusively the nose and its mucous mem- 
brane, and assumes the form of flat or slightly raised, 
sharply defined, isolated or confluent, very hard, lobulated, 
elastic plates, tumors, or nodes which are painful on press- 
ure. These lesions are located in the skin or mucous 
membrane of the septum of the nose, or in the alse and 
the neighboring parts of the upper lip. They can be 
raised from the underlying parts, but the skin is so 
infiltrated that it can move only with the growths. The 
color of the skin may be normal, or bright or dark 
brownish red. They may look like keloids or hyper- 
trophied scars. The contiguous skin shows no abnormali- 
ties whatsoever. The epidermis over the growths often 
shows rhagades, from which exudes a viscid secretion which 
dries into yellowish adherent scabs. 

The disease begins as a thickening and hardening of the 



RHINOSCLEE DMA. 



475 



septum of one or both alte without inflammatory reaction 
or pain. Slowly the nose becomes deformed, broad, and 
flat, and at last by progressive thickening; of both septum 
and alse the nostrils become occluded. The process may 
involve the lips so that the opening of the mouth becomes 
greatly lessened, and may aifect the gums. More fre- 
quently it proceeds backward along the nostrils on to the 
velum palati. The growth shows little tendency to ulcera- 
tion or retrograde metamorphosis. At the most superficial 
parts excoriations occur. Late in the disease the teeth 

Fig. 61. 




Rhinoscleroma. 



may loosen and fall out, and the gums may atrophy. 
The disease begins in some cases in the pharyngeal vault. 
The epiglottis and larynx may be involved in the process, 
and aphonia, suffocative or epileptic-like attacks may 
occur. There is no constitutional disturbance, and the 
only subjective symptoms are those of discomfort on 
account of the interference with respiration. The dis- 
ease is steadily progressive, shows no tendency to recov- 
ery, and recurs rapidly when the diseased parts are cut 
away. 



476 DISEASES OF THE SKIN. 

Etiology. All conditions of men are affected, and 
both sexes with about equal frequency. It usually begins 
between the fifteenth and fortieth years. It is most fre- 
quent in warm climates, and is specially prevalent in 
Austria and Russia. A bacillus has been found in the 
tissues by Frisch that is regarded as the cause of the dis- 
ease. It is described as short, thick, ovoid, capsulated, in 
free groups and in cells. 

Diagnosis. The location upon the nose and upper lip 
alone, the ivory hardness of the growths, and their pro- 
gressive course without tendency to ulceration or soften- 
ing, will establish the diagnosis as against syphilis, epithe- 
lioma, and sarcoma. Keloid rarely occurs upon the nose, 
and never runs the characteristic course of rhinoscleroma. 

Treatment. Treatment is very unsatisfactory. The 
growths may be excised or curetted away, but neither 
process will assure against a relapse. The nostrils may be 
kept open by means of sponge-tents, and the like. Bes- 
nier 1 recommends boring into the tissues with points of 
chloride of zinc for the purpose of giving passage to air. 
Pyrogallic acid, ten per cent, in vaseline, has been recom- 
mended as of value. 

Prognosis. The prognosis is bad. The disease is 
progressive, and threatens life by suffocation on account 
of involving the larynx. 

Rhus-poisoning. See Dermatitis venenata. 

Ringed Hair. See Canities. 

Ringskurv. See Trichophytosis. 

Ringworm. See Trichophytosis. 

Rissopola Lombarda. See Pellagra. 

Ritter's Disease. See Dermatitis exfoliativa neonato- 
rum. 

Rodent Ulcer. See Epithelioma. 

Rosacea. Synonyms : Acne rosacea ; Gutta rosacea seu 
1 Ann. de derm, et de syph., 1891, ii., 603. 



ROSACEA. 477 

rosea ; Acne erythematosa ; (Fr.) Acne rosee, Couperose, 
Rosacee ; Rosee ; (Ger.) Kupferrose, Kupferfinne, Kup- 
frigegesicht. 

A chronic disease of the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that often occur with the disease 
are not true acne pustules it is best to drop the " acne " 
from its title. 

Symptoms. Rosacea is one of the more common skin 
diseases, and is peculiar in affecting, with few exceptions, 
only the middle third of the long diameter of the face — the 
forehead, nose, and adjacent portions of the cheeks, and 
the chin. The nose may be affected alone, and in many 
cases the forehead escapes entirely. The disease has three 
forms or stages. The first consists in a simple redness of 
the affected skin with more or less well-marked dilatation 
of the capillaries. In the second stage there is an added 
element of superficial papules and pustules, and perhaps 
nodules. In the third stage there is marked hypertrophy 
of the skin. The process may stop at any stage. An oily 
seborrhoea may complicate the disease, Unna even claim- 
ing that his seborrhoeal eczema is the first stage of all cases 
of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot 
fluids, exposure to cold, and the like. This being re- 
peated, permanent dilatation of the capillaries takes place. 
The dilated capillaries are not evident all over the patch. 
The greater part of the patch may present an even red- 
ness. The border of the patch is ill defined, and no 
•matter how fiery red the color may be the skin feels cool 
to the touch. This is because the congestion is passive on 
account of a sluggish circulation. In some cases, however, 
there may be but little general redness, only a number of 
dilated capillaries. These telangiectases are best seen on 
the nose. In some cases there may develop a congestive 
seborrhoaa or even an erythematous eczema, which, yield- 



478 DISEASES OF THE SKIN. 

in«; to appropriate remedies, leaves behind an undoubted 
rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be almost 
coincident with it. The number of papules and pustules 
may be considerable, and the tubercles large. If so, the 
amount of redness will be great. The peculiar feature of 
the pustules is their superficiality. They are usually quite 
small, say of pinhead size, and when pricked give exit to 
but a small drop of thin pus. The tubercles are enlarged 

Fig. 62. 




Rhinophyma. (Lassar.) 

or clogged sebaceous glands, but all these lesions are but 
secondary to the chronic hyperaemia, and not primary, as 
in acne. There may also be comedones and true acne 
scattered over the face. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyper- 
aemia leads to an increase of connective tissue, and the 
nose, tip and sides, becomes converted into a lobulated mass 
of tissue, sometimes so great as to form pendulous tumors 
banging down over the mouth. This last condition is 



ROSACEA. 471) 

known as rhinophyma. The whole nose is of deep-red or 
purple color, and studded over with crater-like openings, 
leading down into the thickened mass. At times ulcer- 
ation occurs in these crypts and causes additional annoy- 
ance and deformity from destruction of tissue. 

While in the vast majority of cases the middle third 
of the face alone is affected, in some cases the whole face 
becomes red, and the redness may extend down upon the 
neck. Rosacea is seen at times on the scalp of bald- 
headed persons just above the forehead. 

Etiology. The cause of the disease is probably a 
vasomotor reflex neurosis. Schwimmer regards it as a 
tropho-neurosis ; Unna, as a seborrhoeal eczema. It occurs 
in adult life, most frequently after the twenty-fifth or 
thirtieth year, though it may occur even at puberty. There 
is no connection between it and acne. While many patients 
Avill tell you that they had " pimples " when young, as 
many will inform you that they have always had a good 
complexion until the rosacea began. Women are more 
frequently affected than men. Digestive disturbances are 
a very common cause of the disease, and the trouble may 
be located either in the stomach, intestines, or accessory 
digestive organs. Drinking of alcoholics will undoubtedly 
cause it, on account of producing both gastric catarrh and 
reflex dilatation of the facial vessels. The inordinate use 
of strong tea acts in the same way, and probably gives 
rise to as many cases as does alcohol. Exposure to the 
weather or to extremes of temperature will cause rosacea 
without digestive disturbances, but when combined with 
the latter leads 0:1 to the most brilliant examples of it. 
Constipation, menstrual derangements, ansemia, chlorosis, 
gout, lithsemia, the menopause, each one has been noted 
in connection with rosacea. The use of cosmetics has 
been followed by it. Various morbid conditions of the 
mucous membrane of the nose have been found in con- 
nection with it. Tight lacing is frequently followed by 
rosacea. 

Pathology. In the first stage there is dilatation of 
the blood vessels in the cutis. In the second stage this 
is more pronounced, and the corium is slightly thickened 



480 DISEASES OF THE SKIN. 

and (edematous in places. In the third stage there is in 
addition enormous hyperplasia of the connective-tissue 
elements of the cutis, and the sebaceous glands are en- 
larged. (Elliot.) 

Diagnosis. When we meet with a case of redness of 
the skin, with or without papules, pustules, or tubercles, 
that is limited to the middle third of the vertical diameter 
of the face, it is probably one of rosacea. It differs from 
acne in its limited area, the superficial character of the 
pustules, the absence of comedones, and the capillary dila- 
tation. Lupus erythematosus may occur in the same loca- 
tion, but in it we do not find the dilated capillaries \ but 
we do find thickening of the skin, adherent scales with pro- 
longations from their under side, a sharply defined, slightly 
raised border to the patches, and, if the disease has lasted 
any time, more or less delicate cicatricial tissue. In its 
early stage the diagnosis is not always easy. Lupus 
vulgaris should not confuse us, as in rosacea there is an 
entire absence of the characteristic apple-jelly-like tubercles 
of lupus. The tubercular syphilide may resemble rosacea 
in its second or third stage, but soon it undergoes softening 
and ulceration — processes that do not occur in rosacea. 
Moreover, it is not symmetrical, but occurs in the form of 
groups of tubercles, presents no telangiectases, and evi- 
dences of other syphilides are usually to be found. Ery- 
thematous eezema burns and itches, the skin is somewhat 
swollen and scaly, and feels harsh and leathery. Some- 
times an eczematous condition complicates a rosacea, and 
the latter declares itself only when the former is cured. 

Treatment. In order to treat rosacea successfully we 
must first endeavor to remove the cause. We must in- 
quire as to the condition of the digestive apparatus, the 
manner in which menstruation is performed, exposure to 
heat and cold, and, in fact, ascertain the patient's general 
condition. Then we must address ourselves to the regu- 
lation of any deranged function. We must stop the use 
of alcoholics in any form, and the ingestion of all hot 
fluids, such as tea, coffee, and soup. All these tend to 
produce dilatation of the blood vessels of the face and to 
keep up those conditions we wish to remove. The patient's 



ROSACEA. 481 

diet should be carefully regulated, and such things as 
pastry and sweets cut off, so as to make digestion as easy 
as possible. Medicinally, tincture of nux vomica, the 
mineral acids, or alkalies are to be administered q. r. n. 
Nux vomica has often seemed to render good service, even 
without there being marked digestive disturbance. Salol 
is a good remedy in many cases of intestinal fermentation. 
Ergot or ergotine proves useful in some cases, either with 
or without uterine disturbances. Ichthyol is commended 
by Unna. The ammonia-sulphate is the preparation he 
advises, and it is best given in capsules to cover the taste. 
The dose is three drops two or three times a day. In a 
rather extensive trial of this by me in some sixty cases in 
which it was used alone, with no external application, the 
result was unsatisfactory, only one or two cases being 
benefited. Ichthalbin has been substituted for ichthyol, 
and some good results from its use have been reported. 

The local treatment is important in hastening a cure, 
but is not of itself curative in well-marked cases of reflex 
rosacea. The patient must be instructed to protect the 
skin from the action of wind and weather, by either apply- 
ing some ointment, such as cold cream, or a lotion, such as 
the calamine lotion, or a powder, such as cornstarch, before 
venturing out of doors. The face should be bathed with 
hot water every night before going to bed, the water being 
as hot as the skin can stand without burning, and it should 
be sopped on for about ten minutes, fresh supplies of hot 
water being added from time to. time so as to maintain a 
uniform temperature. This is beneficial because the 
primary dilatation of the vessels caused by it is followed 
by contraction. After the bathing the following lotion 
should be applied : 

R Zinc, sulphat., \ ^ -.3, 

Potass, sulphuret., j ,JJ 

Aquae rosse, ad giv., ad 100) M. 

It is, perhaps, as good as any application we can make. 
Yan Harlingen gives another good one as follows : 



3J; 


12 


gr. v; 


1 


gr. x; 


2 



482 DISEASES OF THE SKIN. 

R Sulphur, praecipitat., 
Pulv. cam phone, 
Pulv. tragacanth., 

Instead of lotions, sulphur ointment (oj-oj) or the white 
precipitate ointment may be used, or simply powdered 
sulphur. In obstinate cases Vleminckx's solution may be 
used. It is composed as follows: 

R Calcis, giv; 15j 

Sulphur, sublimat., .^j ; 30 

Aquse destillat., 3*; 300| M. 

Boil together with constant stirring, until the mixture 
measures six fluid ounces, then filter. This is to be 
diluted four or five times at first, and used at night only, 
followed by cold cream in the morning. The dilution is to 
be lessened by degrees. 

Any of these remedies may produce a dermatitis, fol- 
lowed by desquamation, which is to be desired. For this 
purpose we may use resorcin, ten to twenty per cent, in 
vaseline, stopping it as soon as the skin begins to peel, when 
the skin is to be dressed with cold cream until the irrita- 
tion has subsided. Then the resorcin is to be used again. 
Hillairet ' recommends washing the face in the morning 
with hot water, followed by a solution of oxide of zinc, 
three or four grains to the ounce, sopped on for half an 
hour. Before going to bed the following is to be applied 
to the face : 

R Alcohol, cam pliorat., ."ii-iiiss; 8 ad 15 

Sulphur, sublimat., ijj ; 30 

Aquse destillat, ad^viij; ad 250 M. 

After six days this is to be discontinued for a couple of 
days, and then begun again. 

Eehthyol, in five to fifty per cent, strength in aqueous 
solution, has been highly extolled by Unna and others, as 
well for external as for internal use. 

G. W. Wende 2 reports a cure by using galvanism. 

1 Progres meU, 1880, viii.. 182. 

* Buffalo Med. Journ., 1898-9, xxxviii., 254. 



ROSACEA. 483 

placing the anode over the abdomen and the cathode on the 
face. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a 
few days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hyper- 
trophic tissue. Pustules are quickest removed by the 
curette, as in acne. Dilated vessels are best destroyed by 
electrolysis with the electric needle attached to the nega- 
tive pole, introducing it perpendicularly into the vessel at 
one or more points of its course, or longitudinally in its 
course, and letting it remain for a few seconds until the 
vessel appears as a white line. The method of using 
electrolysis is more fully described under hypertrichosis. 
It is often necessary to repeat the operation several times 
before the vessel is destroyed. The thermo-cautery may 
also be used in the same way. Multiple scarification is 
most useful in reducing red patches. It may be done by 
means of a scalpel, making parallel lines near together and 
through the skin, and then a second series over these ; or 
a multiple scarifying-knife, as sold in the shops, may 
be used for the purpose. H. Fournier 1 advises the use of 
a flat needle rounded at its end and bevelled on its under 
side. The vessels are to be cut obliquely to their long 
axis, while the skin is put on the stretch. After scarify- 
ing, bleeding should be encouraged for a few moments by 
the application of hot water. Then the surface should be 
swabbed over with a solution of carbolic acid, two drachms 
to the ounce of glycerin and Abater. This will check 
the bleeding and constringe the vessels. No after-treat- 
ment is needed, as a rule. If reaction tends to go too 
far, a soothing ointment may be applied. The operation 
should be repeated once every week or two. Multiple 
punctures may be made by the acne lancet, the subse- 
quent treatment being the same as after multiple scarifica- 
tions. It is astonishing to see how rapidly the redness will 
be reduced in many cases, and this without deformity 
1 Journ. mal. cutan., etc, 1895, vii., 257. 



484 DISEASES OF THE SKIN. 

being caused. Multiple scarifications may be employed 
for the reduction of tuberculated masses — rhinophyma — 
but a plastic operation is the most satisfactory method of 
treatment. 

Prognosis. In cases of rosacea arising from exposure 
to weather in drivers and sailors, and in those following 
similar pursuits, we cannot expect to effect a cure, as the 
patients cannot do the one thing necessary — give up their 
occupations. In most all other cases we can promise 
great amelioration of the annoying redness, and in many 
we can effect a cure ; but we had best not attempt to treat 
a patient who will not follow our directions as to diet and 
hygiene. 

Rose. See Erysipelas. 

Rose"e. See Rosacea. 

Rose Rash. See Erythema. 

Roseola. See Erythema roseola. 

Roseola Pityriaca. Sec Pityriasis rosea. 

Roseola Syphilitica. Sec Macular syphilide. 

Roseole Squameuse. See Pityriasis rosea. 

Rotheln, Rubeola, or German measles, is a mild con- 
tagious disease that resembles measles, but differs from it 
in the mildness of all its symptoms, in the lighter color 
and smaller size of its lesions and in the absence of the 
crescentic arrangement of them. Its period of incubation 
is two to three weeks. Like measles, it may be mistaken 
for either an erythema or an erythematous syphilide, and 
its diagnosis is along the same lines as is that of measles, 
which see. It is not so blotchy as measles, and the catar- 
rhal symptoms are absent or but slight. Swelling of the 
glands of the neck is a symptom that may or may not be 
present, but when present is characteristic. Febrile move- 
ment is slight. The lesions may take the form of small 
papules, ami assume rather a brownish than a red color. 
The eruption is often itchy, and the lesions may occur on 
the mucous membranes. It differs from scarlatina in the 



SARCOMA. 485 

mildness of all its symptoms, and in the absence of the 
diffuse scarlet eruption of the latter disease. 

Rothlauf. See Erysipelas. 

Rbtz. See Equinia. 

Rupia. See Syphilis. 

Rupia Escharotica. See Dermatitis gangrsenosa infantum. 

St. Anthony's Fire. See Erysipelas. 

Salt-rheum. See Eczema. 

Salzfluss. See Eczema. 

Sarcocele of the Egyptians. See Elephantiasis. 

Sarcoma. We are here interested in sarcoma of the 
skin alone. Sarcomas may be primary in the skin, but 
most often they are secondary. They form variously sized 
tumors, but tend to run a malignant course, multiplying 
more or less rapidly, breaking down, affecting internal 
organs by metastasis, and killing the patient in a few 
months or years. There are three types of sarcoma, 
namely, the round-cell sarcoma, the small-cell sarcoma, 
and the melano- or pigment sarcoma. Very commonly 
sarcomata are of mixed type ; or sarcomata may be divided 
into two varieties — the pigmented and the non-pigmented. 

According to Brocq, 1 who, following Perrin, has made 
an exhaustive study of the disease, primary melanotic sar- 
coma originates frequently from an irritated nsevus or 
other pigmented lesion, but may occur independently. At 
first it is always single and small. It tends to enlarge 
and attain the size of a nut. In shape it is oval or spher- 
ical. It is nearly always sessile. Its color is dark blue 
or black. It is very hard to the touch. It may remain 
stationary for a long time, but in course of time new 
tumors will appear, either about the original one or at 
distant points by means of the lymphatics. Some of the 
original tumors will disappear, while new ones appear; 
some will break down and form irregular ulcers whose 
floors are black and uneven, and secrete a thick, melanotic 
1 These de Paris, 1885. 



486 DISEASES OF THE SKIN. 

liquid, or a little pus, or almost solid black matter. A 
large tabulated mass may be formed by the coalescence of 
a number of smaller lesions. The viscera become in- 
volved, and death soon occurs. 

A rare form of melanotic sarcoma is described by Hutch- 
inson as melanotic whitlow, which at first is a chronic ony- 
chitis, the border of which looks like a lunar-caustic stain. 
It very gradually develops into a fungating tumor, slightly 
pigmented. The nail is shed, and generalization occurs 
(Crocker). 

Non-pigmented primary sarcoma may lie generalized or 
localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard oedema, accompanied by tension of the skin, and 
perhaps itching or pricking. It may begin as brownish- 
red, livid, purple, or blue patches, upon which pinhead- 
sized nodules appear, which gradually enlarge. In some 
cases little, infiltrated, isolated, blue or reddish-brown 
nodes will form. Sometimes the first appearance Mill be 
a diffused cyanotic patch, which later will become a bossy 
elevated patch. When the disease is fully developed the 
hands and feet are thick, deformed, infiltrated, as firm as 
cartilage, brown or blue with a red tint. The skin is 
glossy, scaly, uneven. The nodes may be raised, pedun- 
culated, or ulcerated. Similar lesions are found upon the 
rest of the body, though rarely on the trunk. They may 
remain stationary, disappear, fall off, multiply, ulcerate, 
or, finally, involve the mucous membranes, and cause 
death. 

The localized form develops ordinarily from an irritated 
nsevus, and is most often encountered on the extremities. 
It forms a hard, wrinkled tumor, which may ulcerate. Its 
color is usually that of the normal skin, though it may be 
red. It may grow to be the size of an orange or take on a 
mushroom-like form. It may not generalize for a long 
time, or it may do so spontaneously or after an attempt at 
removal. 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Under the name of idiopathic multiple pigmented sarcoma 



SARCOMA. 487 

a disease was first described by Kaposi. It occurs in 
adults, and begins as an oedema of the hands, feet, and 
face with more or less pruritus. Later dark-blue or 
purplish spots appear deep in the skin, which after a time 
form raised nodules, which may be sessile or pedunculated, 
but are always dark blue or purple. The extremities or 
face become elephantiasic in appearance, and covered with 
scales and more or less rugous. The tumors may remain 
for a long time or disappear, or, rarely, ulcerate. The 
color of the tumors is due to vascular development. The 
disease is chronic in its course, and may last for fifteen or 
twenty years without affecting the patient's health. The 
disease may extend up the limbs to the trunk. Recovery 
may take place. 

Etiology. We know very little in regard to the eti- 
ology of sarcoma. It occurs at all ages, some of the most 
malignant eases being seen in childhood. Brocq says that 
the localized non-pigmented sarcoma is most frequent in 
women, and that the generalized form is most frequent in 
robust men of forty to sixty years. Piffard gives the 
ages at which they are most prone to occur as before the 
fifteenth and after the forty-fifth year. 

Diagnosis. The diagnosis of sarcoma is generally easy, 
but at times it is difficult. The pigmented forms are 
usually readily recognizable by their color. The non- 
pigmented single sarcoma may be distinguished from 
epithelioma by its feel, which, though firm, lacks the 
hardness that is characteristic of cancer. Fibromata are 
not so firm as are sarcomata, are more commonly pedun- 
culated, and show no tendency to degenerative changes. 
Mycosis fungdides has a primary eczematous stage ; its 
tumors are of a brighter red, and they come and go, and 
undergo various changes much more rapidly than do sar- 
comata. 

Treatment. Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcomata, and in the 
melanotic variety, operative interference is usually not 
only not curative, but has often seemed to hasten general- 
ization. Kobner and others have used hypodermic in- 
jections of arsenic with brilliant results in some cases. 



488 DISEASES OF THE SKIN. 

Kobner used Fowler's solution of half strength, and in- 
jected two and a half to four drops of it once a day. 
After three months the dose was increased to seven and a 
half, and then to nine drops. Others have tried arsenic 
without effecting a cure. Still it is worthy of trial, as it 
may cure the disease if it is well borne by the patient. 
Inoculation by the toxin of the streptococcus has cured 
some cases, but its use is not without danger to the life of 
the patient. 

Prognosis. This is always grave. The course of the 
disease is nearly always from bad to worse, though the 
fatal result may not be reached for many years. Melanotic 
sarcoma is more rapidly fatal than is the ordinary form. 

Satyriasis. See Lepra. 

Scabies. Synonyms: The Itch; (Fr.) Gale; (Gr.) 
Kratze. A contagious disease of the skin due to its inva- 
sion by the acarus scabiei, and characterized by excessive 
itching, worse at night, and by excoriated lesions, pustules, 
and cuniculi upon the anterior face of the wrists, between 
the fingers, on the breast of females, the penis of males, 
and about the umbilicus of both sexes. 

Symptoms. The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the 
disease. Itching is always present in it. While it may 
be somewhat in abeyance during the day, it is hardly ever 
absent, and at night in bed it is so bad, in susceptible in- 
dividuals, that sleep is well-nigh impossible. The itching 
gives rise to scratching, and the scratching to the secondary 
symptoms of the disease — scratched papules and eczematous 
patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he scratches, and sooner or later, 
according to the resistance of his skin, he produces pin- 
head-sized excoriations. Later, the irritation continuing, 
eczematous patches result. When he presents himself to 
the physician, the latter will Hud on examination excoria- 
tions due to scratching, and he Mill notice that the lesions 
are located principally between the fingers, on the anterior 
surface of tlie wrists and somewhat on the forearms, about 



SCABIES. 489 

the axillae, upon the breasts about the nipples in women, 
upon the male genital organs, about the umbilicus and 
lower part of the abdomen, and often upon the buttocks 
of both sexes, and, in children especially, upon the anterior 
surface of the ankles and between the toes. In adults, 
these latter situations are not so frequently affected. Closer 
examination may be rewarded by the discovery of the 
pathognomonic sign of scabies, namely, the cuniculus, or 
burrow, which is usually found most readily on the inner 
border of the hand, on the inside of the fingers, and on 
the penis. It forms a delicate, slightly raised, whitish or 
grayish, wavy, often bowed line, from one-eighth to one- 
half an inch in length, and having a white speck at one 
end which marks the place where the itch-mite is. These 
are not always to be found ; indeed, in most cases they are 
difficult to find, because they are broken up either by the 
occupation of the individual, by the use of soap and water, 
or by scratching. In people with delicate skin the burrow- 
ing of the itch-mite will set up an inflammatory process, 
and papules, vesicles, and pustules will form, quite inde- 
pendently of the scratching. 

While the regions mentioned are the ones always affected 
in well-marked cases, variations in the extent of the dis- 
ease are observable. In some cases the hands are free, 
and but few lesions are present anywdiere. Here, if it is 
a male, the crucial test will be the examination of the 
privates,, where a scratch-mark or a burrow will be found 
almost without fail. In other cases hardly any part of the 
body will be free from excoriations, pustules, or eczematous 
patches, excepting the face, which is affected only excep- 
tionally, and then nearly always in children. In these bad 
cases furuncles and large ecthymatous pustules join them- 
selves to the already multiform eruption of scabies. Urti- 
caria is also present in some cases, its wheals being 
interspersed among the other lesions. Should some inter- 
current fever arise, the symptoms of scabies will subside, 
to reappear when the fever is past. The so-called Norwe- 
gian Itch is only a very much aggravated form of the 
disease, on account of the want of personal cleanliness of 
the people. The face in this form may be affected, the 



490 



DISEASES OF THE SKIN. 



nails split and shed, and the palms and soles covered with 
thick crusts. 

Etiology. Scabies is due to the irritation set up by 
the acarus scabiei and by the scratching employed to re- 
lieve the same. The vesicles, papules, or pustules about 
the burrows are due directly to the acarus ; it may be on 
account of some irritating substance secreted by it. The 

Fig. 63. 




Acarus scabiei. Back. 



disease is contagious, but requires prolonged contact, as 
by holding the hand or sleeping with an infected person. 
It is very rare for it to be communicated to a physician in 
examining a patient. 

According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after 
the fiftieth year. This, lie thinks, is due to the fact that 
i Boston Med. and Surg. Jouni., Sept. 23, 1S86. 



SCABIES. 



491 



in advanced life the epidermis becomes harder and dryer, 
and forms a less suitable habitat for the acarus. A few 
years ago the disease was not common in this country, 
but now it is an every-day occurrence to meet with new 
cases in our dispensaries, and not an infrequent one to 
meet with it in private practice. 

Pathology. The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 

Fig. 64. 




Acarus scabiei. Under surface. 



sixtieth to one-eightieth of an inch long, and the male 
still smaller. Its width is about two-thirds of its length. 
It has eight legs — four on each side of its head, to which 
suckers are attached, and four posteriorly, to all of which, 
in the female, bristles are attached ; while in the male the 
inner ones are wanting in bristles, but provided with 
suckers for attaching himself to the female in copulation. 
On the back are a number of short bristles. A glance at 



492 



DISEASES OF THE SKIN. 



the accompanying plates will describe the animal better 
than words. 

The impregnated female acarus having landed on the 
skin, soon stirs about, and having found a suitable place, it 
rests on its hind feet, takes an oblique position, pierces the 

Fig. 65. 




Burrow of scabies with acarus. (After Kaposi ) 

skin, and bores a hole, into which it forces itself. It lodges 
in the deeper layers of the epidermis, above, and sometimes 
in the mucous 'layer. It bores a burrow equidistant be- 
tween the surface of the epidermis and the level of the 



SCABIES. 493 

papillae of the corium. Being prevented by the bristles on 
her back from moving backward, she moves forward, and 
lays her eggs. Her duration of life is from six weeks to 
two months, and during this time she lays some fifty eggs. 
These hatch out, reach the surface of the skin, meet the 
male, become impregnated, bore in their turn into the 
skin, and so keep up the process. As the thinnest parts 
of the skin are most easily punctured, it is just in these 
parts that we find the lesions most commonly. The 
scratching often extends far beyond the sites of the bur- 
rows. Fournier found that an acarus died in seven days 
when immersed in cold water, in ten days when in warm 
water, and in two to four days in a solution of green soap. 
He denies the commonly accepted view that the acarus is 
a night-prowler, though he allows that it is most active at 
night. 

Diagnosis. The presence of pustules and scratch- 
marks between the fingers, on the anterior face of the 
wrists, about the umbilicus, on the breasts in women or the 
genitals in men, is enough to make the diagnosis of scabies. 
If a cuniculus can be found, it will be corroborative evi- 
dence. Eczema is more patchy and is not so markedly 
limited to the characteristic locations of scabies. Pedicu- 
losis vestimentorum presents long, parallel scratch-marks 
instead of the small excoriations of scabies, and their char- 
acteristic locations are over the shoulders, about the girdle, 
and along the outside of the arms and the inside of the 
thighs where the seams of the clothing come. The itch- 
ing of scabies is worst at night, while that of pediculosis 
is most marked in the daytime. Urticaria is a general 
disease characterized by wheals, and shows no tendency 
to localize itself in certain regions. Should urticaria com- 
plicate scabies, the wheals will be disseminated while the 
lesions of scabies will be most marked in their character 
istic locations. 

Treatment. If the disease is recognized, there is no 
difficulty in curing it, though there are various methods 
employed. Perhaps the oldest and one of the most reli- 
able, though not the most rapid " cure," is to have the 
patient take a warm bath with soap and water, scrubbing 



404 DISEASES OF THE SKIN. 

himself thoroughly so as to remove as much of the old 
epidermis as possible. Then he should dry the skin with 
vigorous friction, and rub into every diseased spot ordi- 
nary sulphur ointment. When this is done he should smear 
the rest of the skin with the ointment, put on the same 
clothes, and go about his business. The rubbings with 
the ointment are to be repeated morning and night for 
three days, the patient wearing the same underclothing by 
day, and bed- and night-clothing by night. At the end 
of three days another bath is to be taken, the clothing 
changed, and the patient should then present himself for 
examination. If fresh lesions are found, a second course 
should be taken, which most always will be sufficient. 
An artificial eczema is apt to be set up by the sulphur, 
and as eczema itself itches we must not take the continu- 
ance of pruritus beyond the second course as evidence of 
the scabies not being cured. It is better to stop the sul- 
phur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaseline and corn- 
starch. If the itching grows worse instead of better, a 
third course of rubbing must be gone through with. In- 
stead of plain sulphur ointment we can add balsam of 
Peru, about half a drachm to the ounce, or use the modi- 
fied Wilkinson's ointment, as follows: 

R Sulph. sublimat., ") .- . 

Ol. cadim, I d ' 

Creta prseparat., oiiss; 

Sapo viridis, ) -- -• 

Adipis, 1 aa & ; p- ■• « iw M . 

S. Sherwell, ' instead of using sulphur in ointment form, 
has the patient rub into the skin the dry sulphur powder 
and throw in between the sheets of the bed a half teaspon- 
ful of the same. I have tried this plan in private practice 
with perfect success. It is vastly more agreeable than 
using an ointment. This, though a very efficient remedy, 
tonus such a disgusting-looking mass and is so irritating 
that it is fit only for public practice. /3-naphtol, in five to 
ten per cent, strength in ointment or oil, is a good remedy, 
1 New York Mod. Journ., 1893, i, 432. 



aa 


16 




10 


ad 


100 



SCABIES, 495 

free from the sulphur smell, and not so irritating. Kaposi 
recommends it in the following form : 

R /3-naphtol., 15 parts. 

Sapo.viridis, 50 " 

Cretfe alb. pulv., 10 " 

Adipis, 100 " M. 

and Crocker says : " I can speak of it in the highest 
praise." It is well fitted for private practice. McCall 
Anderson extols styrax liquida with a double amount of 
lard. As the itch is very prevalent in Scotland, the doc- 
tor should know of what he speaks. Too free use of this 
remedy may cause a nephritis, so patients using it must be 
watched. 

The treatment in the St. Louis Hospital of Paris is a 
heroic one, but is said to cure in one hour and a half. 
According to Fournier, the patient is scrubbed violently 
for half an hour with green soap ; then for another half- 
hour the scrubbing is continued while he is in a bath ; 
then he is rubbed with Helmerich's ointment : 

R Potnsi. carbonat, .^ss ; 15! 

Sulphur, sublimat., %\ ; 30: 

Adipis, g'iv; 120 M. 

Now he puts on his clothes without removing the salve, 
and is discharged cured. In private practice Fournier 
recommends the use of a good toilet soap for the prelim- 
inary rubbings, and then Bourguignon's ointment as fol- 
lows : 

R Glycerini, 200 parts. 

Gum. tragacanth., 5 " 

Sulph. sublimat., 100 " 

Potass, carb., 35 " 

01. lavandula?, "] 

01. menth pip., |. -- 15Q „ M 

Ol.carvophylli, j 
Ol.cinnamomi, J 

This is to be followed by a bath and powdering with corn- 
starch. It cannot be used for children, or in extensive 
cases in adults where there is much excoriation. 



496 DISEASES OF THE SKIN. 

For infants and young children, balsam of Peru is 
the pleasantest application we can make, it being rubbed 
in morning and night, either pure or diluted with sweet 
oil ; or a mitigated form of sulphur ointment may be used. 
It is possible to cause constitutional symptoms by using 
the balsam of Peru, but this is rare. 

In all cases the clothing and bedding must be disin- 
fected — washable things by boiling, and cloth clothing by 
baking or by ironing with a very hot iron. All affected 
members of the family must be treated at the same time. 
An irritable condition of the cutaneous nerves sometimes 
lasts long after the scabies is cured, and must not be mis- 
taken for a still active itch. 

Prognosis. The prognosis is always good, provided 
the applications are made thoroughly enough. 

Scall or Scalled Head. See Favus. 

Scarlatina. Scarlet fever is an acute contagious eruptive 
disease with an incubation period of one day to two or 
three weeks, with an average of eight days. It is char- 
acterized by a quick rise of temperature at the beginning, 
redness of the fences, a strawberry tongue, and the appear- 
ance of a hue punctate scarlet rash, which, first appearing 
on the neck, chest, and flexures of the joints, rapidly 
spreads over the whole body. The redness may be even 
over all, so as to give a boiled-lobster appearance to the 
skin ; or the red points may be distinct, although close 
together. The redness usually disappears on pressure. 
Vesicles may appear. A great deal of constitutional dis- 
turbance and prostration usually attend the eruption, but 
convalescence is well established in the second week iu 
uncomplicated cases. Abundant desquamation follows the 
subsidence of the eruption, which continues for days or 
weeks. 

Diagnosis. There is often a striking resemblance be- 
tween scarlatina and erythema scarlatiniforme, and some 
other erythemata. (See Erythema.) 

Scherende Flechte. See Trichophytosis capitis. 

Schmeerfluss. See Seborrhoea. 



SCLEREMA NEONATORUM. 497 

Schuppenflechte. See Psoriasis. 

Scissura Pilorum. See Atrophia pilorum propria. 

Sclerema. See Scleroderma. 

Sclerema Neonatorum. Synonyms : Scleroderma neona- 
torum ; Induratio telse cellulosse ; (Fr.) Algidite progres- 
sive, L'endurcissement athrepsique ; (Ger.) Das Sclerem 
der ISTengeboren. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in 
1877. It may be primary, but most often it is secondary 
to some exhausting disease, such as pneumonia or intesti- 
nal catarrh. It may be present at birth, and rarely oc- 
curs after the first ten days of life. It is characterized 
by hardness of the skin, which generally at first is cir- 
cumscribed and affects the leg. It may be diffused from 
the first, or it soon becomes so, and extends to the lumbar 
regions, back, chest, and so all over the body, becoming 
universal by the fourth day. It may begin on the face, 
and it may stop before becoming universal. It may be 
but slightly developed on the chest. At first the skin is 
pale and waxy ; later, it becomes livid and cold, and the 
child looks as if frozen. The skin becomes attached to 
the underlying parts, smooth, tense, and does not pit on 
pressure. Movement is impossible for the child, and the 
body may be raised without bending a joint. When the 
face is affected it is impossible for the child to nurse. Its 
respirations are greatly reduced in number, its pulse falls 
to sixty per minute, its temperature is below normal, its 
breath is cool, and it dies within a week. The primary 
congenital cases are either stillborn or die in one or two 
days. Localized cases sometimes recover, the hardness of 
the skin disappearing. 

Etiology. The cause of the disease is obscure. It is 
seen almost exclusively in foundling asylums and among 
the very poor. It is, therefore, a disease of depressed 
vitality. Langer 1 regards it as the result of solidifica- 
tion of the fat, which in infants contains thirty-one per 
1 Wien. med. Presse, 1881, xxii., 1375. 



498 DISEASES OF THE SKIS. 

cent, of palmitin and stearin, that of adults containing 
ten per cent. The fat in infants, he says, is nearly all 
concentrated in the subcutaneous tissues, where it is five 
times as thick relatively as it is in adults. Naturally, an 
infant's temperature is higher than an adult's, and, if it is 
lowered by any depressing cause, the fat may solidify. 
Solidification may take place also under the action of cold, 
or by oxidation, as in fevers, withdrawing some of the 
constituents of the fat. Parrot regards the disease as one 
of desiccation from the drain of a diarrhoea, or the like. 

Diagnosis. Sclerema neonatorum is differentiated 
from oedema neonatorum by being more general in its dis- 
tribution, by the skin being harder and more tense, and 
not pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 
the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. The course of the disease is almost in- 
evitably toward a fatal termination, and little more can 
be done than to keep the little body as warm as possible, 
to rub in oil, and to administer concentrated nourishment 
and stimulants. Money ' reported a case in 1889 that 
was cured in six weeks by mercurial inunctions. There 
was no history of syphilis in the case. 

Scleriasis. See Scleroderma. 

Sclerodactylia. See Scleroderma. 

Scleroderma. Synonyms : Sclerema sen Scleroma adul- 
torum ; Scleriasis; Dermato-sclerosis ; Chorionitis; Scler- 

ostenosis ; (Fr.) Sclereme <\e> adultes, Sclerodermic ; (Ger.) 
Hautsclereme ; Hide-bound disease. 

A subacute or chronic disease, characterized by hardness 
and rigidity of the skin. 

Symptoms. The name of this disease indicates the most 
peculiar feature of it — that is, hardness of the skin. It 
may come on without apparent cause, the patient first 
noticing the stiffness of the skin ; or it may follow expos- 
ure to dampness and cold, and be preceded by pains of 
1 Lancet, 1889, i., 526. 



SCLERODERMA. 499 

rheumatic nature. It may begin in any part of the skin, 
but has a preference for the upper half of the body. It 
is usually symmetrical, though it may be more pronounced 
on one side than on the other. Having begun, it spreads, 
it may be very slowly, or it may be so rapidly as soon to 
involve large areas of the body. It often runs a capricious 
course, growing better and worse, and leaving sound areas 
in the midst of the diseased parts. There may be one 
patch or a number of patches, and the patches assume many 
shapes, though most commonly they are elongated, run- 
ning lengthwise of the limb. 

There are two varieties of the disease : 1. The infiltrat- 
ing form. In this there is a good deal of infiltration 
of the skin, which is hard, cannot be pinched up, does 
not pit on pressure, and is attached to the deeper struct- 
ures. The appearance given to the affected part is cada- 
veric. In some cases there may be hard oedema. The 
affected part is usually on the level of the surrounding 
parts, though it may be slightly raised. The infiltra- 
tion merges gradually into the neighboring parts, its 
border being ill defined and more readily felt than seen. 
The natural folds of the skin are obliterated, erythema 
may be present at first, and telangiectases are frequently 
observed upon the surface. Not infrequently the patch 
has a lilac border. The color of the skin is paler than 
that of the normal integument, and in some places it 
may be that of ivory. Some scaling may be present, 
or pigmentation of a mottled or diffused character may 
give the patch a fawn to black color. Owing to the 
stiffness of the skin the movement of the joints is inter- 
fered with, a state of pseudo-ankylosis being established. 
If the face is affected, it loses its expression, and the feat- 
ures become immobile. The eyelids may escape for some 
time ; but if the disease passes on to the atrophic stage, 
soon to be mentioned, the eyes become wide open and 
cannot be closed. If the chest is much affected, respira- 
tion is interfered with. The temperature of the skin is 
usually lowered one or two degrees. It may be normal or 
somewhat elevated. Sensibility may be increased, normal, 
or decreased. Pruritus is at times annoying. The secre- 



500 DISEASES OF THE SKIN. 

tions of the skin are lessened with the increase of the dis- 
ease. The disease may invade all the mucous membranes. 

2. The atrophic form may succeed the infiltrating form 
after months or years. Crocker thinks that it is probable 
that atrophy follows the (Edematous infiltration .only. 
When atrophy begins it is progressive, and the skin be- 
comes dry, wrinkled, parchment-like. It is most often 
the upper part of the body that is affected — the face and 
arms. Continuous contraction of the skin produces an 
atrophy of the muscles under it, so that finally nothing 
remains of the original structures but the skin and bones, 
and the joints are ankylosed. The face being affected, we 
will find a corpse-like expression, wide-open eyes with 
ulcerated corneas, shrunken gums with loosened and fall- 
ing teeth. The limbs being affected, slight injuries will 
produce ulcerations over bony prominences, and the limbs 
will be semiflexed. The schrodactylie of Ball is sclero- 
derma of the atrophic variety, affecting the hand and 
causing marked atrophy, loosening the joints, and distort- 
ing the hands, "so that the third and fourth fingers are 
curled up into the hand, the first and second are bent at 
the first phalangeal joint, while the thumb phalanges are 
over-distended." (Crocker.) 

The general health remains unaffected in both forms, 
often for years ; but should the disease be very pronounced, 
at last a marasmic condition develops and death occurs. 
Apart from the pruritus and feeling of stiffness, we may 
have no subjective sensation, excepting that pain on press- 
ure is exquisite. At times burning is complained of. The 
disease, when of the infiltrated variety, tends to a slow 
and interrupted course toward recovery. In the atrophic 
variety recovery may take place. Of course, the atrophied 
skin will never regain its natural texture, but the disease 
may cease to spread and increase. At best its subject is 
but a sorry speeimen. 

Children may have scleroderma, the youngest reported 
case being thirteen months. In them the disease is said 
to run a more rapid course, both in development and re- 
covery, than it does in the adult. Yidal ' describes a 
1 Gaz. des Hop., 1878, li., 939. 



SCLERODERMA. 501 

form of scleroderma following a lesion of the skin, such 
as an eczema, which gives rise to a lymphangitis, and is 
usually met with on the leg. 

Morphcea, Keloid of Addison, is the circumscribed form 
of scleroderma. It occurs either as circumscribed, vari- 
ously sized, oval or irregularly shaped patches, or in the 
form of bands, the former being the more common. It 
begins as a congested, red, rosy, or lilac macule, which en- 
larges, pales in the center, becomes hardened, and assumes 
the form of a characteristic patch of the disease. This 
patch looks like a piece of old ivory or of lard set in the 
skin, being of a yellowish-white color. The color may be 
pinkish, yellow, brown, or even black. The skin over the 
patch is usually smooth and easily pinched up. It may be 
wrinkled, or eroded in the center. It may be level with 
the surface of the skin, or raised above it, or sunken below 
it. Around it is a lilac border due to dilated vessels. 
When the patch is pinched between the fingers it feels 
firm, like leather. There may be but a single patch or a 
number of patches. As a rule the disease is unilateral. 
After a varying length of time it may disappear spon- 
taneously, although it may remain for a number of years. 
There are usually no subjective symptoms, and the disease 
remains unchanged until it disappears. In some cases it 
enlarges by new patches developing at the periphery of 
the old one and uniting with it. Exceptionally there may 
be some itching or pain, and ulceration may occur. Sensa- 
tion is generally preserved. The band form is usually 
single, and may form a depressed sulcus or a raised ridge, 
looking much like a cicatrix. In addition to the bands 
there may be atrophic spots. 

The most common locations of morphcea are anywhere 
on the trunk, but specially on the breasts ; on the head 
and face in the parts supplied by the fifth nerve ; and on 
the limbs. It is not infrequently associated with other 
nervous phenomena, and may occur along the course of a 
nerve, like zoster. Nettleship l has reported a case in the 
region of the first and second divisions of the fifth nerve 
with paralysis of the intraocular branches of the third 
1 Trans. Clin. Soc. Lond., 1882-3, xvi., 199. 



502 DISEASES OF THE SKIN. 

nerve, which in time had associated with it hemiatrophy 
of the whole of the left side of the head. There is no 
disturbance of the general health. The secretion of sweat 
over the patches may be normal, lessened, or absent. 
When the disease disappears it may leave no trace of 
itself; or it may be followed by pigmentation, or even 
permanent atrophy, not only of the skin, but also of the 
muscles. A form of leprosy has been wrongly named 
morphoea. 

Etiology. Women are far more often the victims of 
scleroderma than are men — three to one. It is most com- 
mon in young and middle-aged adults. Apart from this, 
we are in uncertainty as t<> the true cause, though rheu- 
matism, gout, exposure to cold and heat, bad hygiene and 
poor food, and neurotic influences have each been found 
in apparent causative relation to the disease. At the 
foundation of the trouble there is supposed to be some 
defect in the nervous system, not improbably in the vaso- 
motor centers. 

Diagnosis. There is no other disease of the skin with 
which diffused scleroderma could well be confounded, 
excepting sclerema or cedema neonatorum, or cancer en 
cuirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. Cancer 
en cuirasse is more rapidly fatal in its course, is at first 
or soon marked by subcutaneous nodules that tend to 
break down and ulcerate, and is accompanied by lancinat- 
ing pain. 

Keloid differs from morphoea in having claw-like proc- 
esses, in being more vascular and harder, and in wanting 
the old-ivory color and lilac border. Leprosy has anaes- 
thetic patches, which morphoea has not. Vitiligo is a pig- 
ment change only, and has no other symptoms. 

Treatment. It is doubtful if treatment is ever di- 
rectly of avail. At best it is unsatisfactory. A general 
symptomatic treatment with tonics, good diet, and main- 
tenance of the body heat is indicated. Galvanism, in- 
unctions of the skin with oil, and massage may be tried. 
West 1 has reported amelioration in one case by the 
1 Trans. Path. Soc. Lond., 18S3, xvi., 252. 



SCROFULODERMA. 503 

external use of chaulmoogra and olive oils. Graham l 
advises the use of antirheumatic remedies. Hyde has 
obtained benefit by the use of common salt, either moist- 
ening it with warm water until it is partially dissolved, 
and then rubbing it briskly over the entire surface of the 
body excepting the face, and then washing it off with 
water of decreasing temperature until cold water is used ; 
or a warm tub or sponge bath is taken containing one- 
quarter of a pound of salt to the gallon. I have seen one 
case improved by inunctions of vaseline containing ten per 
cent, of salicylic acid. 

Prognosis. While recovery may take place, it is 
uncertain as to its occurrence. Death may result. In 
children the prognosis is more favorable. 

Scleroderma Neonatorum. See Sclerema neonatorum. 

Scleroma Adultorum. See Scleroderma. 

Sclerostenosis. See Scleroderma. 

Scrofulide Boutoneuse Benigne. See Prurigo. 

Scrofulide Crustace'e Ulcereuse. See Tuberculosis cutis. 

Scrofulide Erythemateuse. See Lupus erythematosus. 

Scrofulide Tuberculeuse. See Lupus vulgaris. 

Scrofuloderma. Modern pathology has led, or is leading, 
us to use the term tubercular as synonymous with scrofula, 
and a number of dermatoses that were for many years 
regarded as scrofulodermata have been proven to be due 
to the bacillus tuberculosis. The most brilliant example 
of this is lupus vulgaris. Many of the scrofulides of the 
French have been shown by more careful observation to 
belong to various other well-recognized forms of skin 
disease. The marks of a scrofulous affection are, accord- 
ing to Bazin : (1) the involvement of the deeper layers of 
the skin ; (2) the sharply circumscribed character of the 
lesions ; (3) the absence of pain ; (4) hypertrophy followed 
by atrophy of the affected parts ; (5) the reddish, violaceous, 
or livid color of the lesions ; and (6) indelible cicatrices left 
by the same. 

1 Journ. Cutan. and Gen.-Urin. Dis., 1886, iv., 332. 



504 DISEASES OF THE SKIN. 

In the present condition of our knowledge of the sub- 
ject, and in a book of this sort, it is impossible to do more 
than to place here a few affections of the skin that do not 
fit in under other well-established diseases, while premis- 
ing our remarks by saying that they are either really in- 
stances of cutaneous tuberculosis or due to its toxins, or 
will eventually be taken out of their present position as 
scrofulodermata. In all of them we have, at the same 
time, that general make-up of the individual that long has 
been recognized as scrofulous. The patients are mostly 
young subjects, flabby of flesh, with pasty or doughy com- 
plexions or transparent skins, thick upper lips, perhaps 
with clubbed fingers, a marked tendency to chronic catar- 
rhal inflammations of all the mucous membranes, chains 
of enlarged glands in the neck, and perhaps with some 
old or present bone lesions. They are usually dull and 
apathetic, but may be unusually intellectual, and are prone 
to die with tubercular lung diseases. 

The most common scrofuloderm is that resulting from 
a suppurating caseous gland, usually of the neck — the 
scrofulous uh-cr. The gland, before it breaks down, im- 
plicates the skin over it, and it becomes of violaceous or 
livid color, attached to the underlying parts. By and by 
the skin gives way at one or several points; the sanious, 
unhealthy pus escapes through the openings ; these en- 
large, coalesce with others, and so form the characteristic 
ulcer. This has undermined edges ; is of irregular shape ; 
its base is covered with flabby granulations; it discharges 
a thin, sanious pus; shows little tendency to crusting; is 
almost painless, and heals very slowly, leaving a puckered, 
disfiguring scar that is often bridled, one with bands of 
connective tissue running across the site of the ulcer, 
under which a wooden tooth-pick, or the like, can be 
passed. Only one gland may be affected, or there may be 
a number of them that enlarge and break down. This 
same form of ulcer may originate from what is called a 
scrofulous gumma, a subcutaneous tubercle independent of 
the glands, that slowly enlarges to a soft tumor, breaks 
down, and ulcerates These tumors frequently occur on 



SCROFULODERMA. 505 

the limbs, and the bones may be involved in the destruc- 
tive processes set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
" large, rounded, ovalish, or irregularly shaped, yellow- 
ish, flat pustules, with a deep-red or violaceous areola." 
This begins to crust in the center, and the crust is usually 
flat and scanty, brownish and adherent. Underneath it is 
an ulcer with the characters and course of those just de- 
scribed. There may be one, two, or more lesions. The 
small pustular scrofuloderm " consists in the formation 
of pinhead- and small split-pea-sized, disseminated, yel- 
lowish, flat pustules, with usually a raised, violaceous 
areola." These crust over with depressed yellowish or 
gray adherent crusts, which when removed, or when 
they fall off, leave depressed, punched-out scars resem- 
bling variola. Their course is very chronic and painless. 
They occur upon the face and extremities of strumous 
individuals. This form is probably the same as that now 
called acne necrotica. 

Etiology. The causes of these scrofulodermata are 
those of the strumous state plus infection by the tubercle 
bacillus, and need not be gone into here. They are most 
commonly met with in early life. 

Diagnosis. The scrofulous ulcer differs from that of 
lupus vulgaris in an entire absence of the characteristic 
lupous tubercles, and in its history of beginning in a 
caseous gland. Moreover, in lupus we do not have, as a 
rule, the pronounced strumous condition that we have in 
the scrofuloderm. The pustular scrofuloderms sometimes 
resemble syphilis, but there is an absence of other signs of 
syphilis, and the presence of the strumous state. More- 
over, the pustular syphilide is generally far more dissem- 
inated than is the scrofuloderm ; its course is far more 
acute; it yields more readily to treatment, and leaves a 
smoother, less disfiguring scar. 

Treatment. The treatment of the ulcers, as well as 
the softening glands, is upon surgical principles. The 
regulation of the diet and hygiene of the patient, and the 



506 DISEASES OF THE SKIN. 

administration of cod-liver oil, iron, the compound syrup 
of the hypophosphites, or other tonic, is the most essential 
part of the medicinal treatment. Locally, to the pustular 
scrofuloderma we may apply iodoform ointment, aristol, or 
other antiseptic powder, or mercurial ointments or lotions. 
Crocker speaks well of chaulmoogra oil emulsion in the 
dose of ten to thirty minims, combined with its external 
use as an ointment in the strength of one part to three. 

Scrofuloderma Verrucosum. See Tuberculosis verrucosa 
cutis. 

Scurvy. See Purpura. 

Sebaceous Cyst. Synonyms : Atheroma ; Steatoma ; 
Wen. 

These innocuous little tumors may occur anywhere on 
the body, but are most common on the scalp, face, neck, 
and back. They vary in size from that of a millet-seed 

Fig. 06. 




Sebaceous cysts of scalp. (Hyde.) 



to that of an orange. They may be rounded, flattened, or 
hemispherical. There will be found in many of them a 
small opening, out of which some of their contents may 



SEBORRHEA. 507 

be pressed. The skin over them may be of normal color, 
pale on account of pressure, or red if the cyst becomes 
inflamed. They may be elastic and doughy to the touch, 
or firm, or soft, according to the condition of their con- 
tents, which may be fluid and honey-like, or cheesy. They 
tend to grow slowly, and give no trouble except by the 
deformity they cause. In exceptional cases they may 
become inflamed and ulcerate. The hair is usually absent 
over them when they occur on the scalp. Cysts of similar 
nature may be found in locations where there are no 
sebaceous glands, and even under the mucous membranes. 
These are called dermoid cysts, and are supposed to be left 
over from foetal life. They frequently contain hair and 
teeth. 

Etiology. Most cysts are due to distention of a se- 
baceous gland. They occur in both sexes in adult life, 
being rare in children. The origin of dermoid cysts is 
undetermined. Indeed, considerable uncertainty surrounds 
the pathology of all of them. 

Diagnosis. They must be distinguished from fatty 
tumors and gummata. Fatty tumors are firmer and more 
doughy than cysts, and are more often lobulated, occur but 
seldom on the scalp, and are rarely multiple. Gummata 
are more rapid in their growth, are attached to the skin, 
and tend to break down and ulcerate. 

Treatment. Complete excision of the tumor, taking 
particular care to remove the whole sac, is the only treat- 
ment to be considered. 

Seborrhagia. See Seborrhcea. 

Seborrhoea. Synonyms : Stearrhoea, Steatorrhea, Sebor- 
rhagia, Fluxus sebaceus, Acne sebacea, Pityriasis, Ichthy- 
osis sebacea, Tinea amiantacea seu asbestina, Eczema 
seborrhoicum, Lichen circinatus ; (Fr.) Acne sebacee, Acne 
fluente ; (Ger.) Schmeerfluss, Gneis ; (Ital.) Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may 
be of too fluid or too solid consistence, and forms either 
an oily coating or greasy crusts on the skin. 

Symptoms. Normally the sebaceous glands secrete 



508 DISEASES OF THE SKIN. 

only sufficient oil to keep the skin soft and supple. This 
normal oil is not visible to the naked eye. Uncler certain 
imperfectly understood conditions the glands secrete a too 
fluid and abundant oil that is readily seen as an oleaginous 
coating of the skin. This form of seborrhoea is called 
scborrhcea oleosa, and by many authorities is now declared 
to be the only form of seborrhoea. By others, and per- 
haps the majority, it is thought that under certain other 
equally imperfectly understood conditions the secretion of 
these glands is not only too abundant, but also too con- 
sistent. Then the sebaceous matter cakes upon the skin 
in the form of more or less thick plates or masses, and to 
this condition the name of scborrhcea sicca is given. The 
latter form is regarded by those who believe that there is 
but one form of seborrhoea as seborrhoeal dermatitis or 
eczema. In deference to the older teachings, both forms 
will be described. 

The most common locations of seborrhoea are, naturally, 
those regions where the sebaceous glands are the largest 
or most numerous, namely, the scalp, the chest, the in- 
terscapular region, and the face. 

Scborrhcea oleosa, while it may occupy any or all of these 
regions, is usually subjected to us for treatment only when 
it occurs upon the face. Here it is seen most often on the 
nose, where it forms a greasy coating. At times this is so 
slight as to be felt rather than seen, imparting a slippery 
sensation to the finger. At other times it is so abundant 
that it can be seen at a distance as drops or beads of oil, 
and when it is removed with a cloth or blotting-paper it 
leaves an oily stain upon it. When it is wiped oif it at 
once reforms. As the greasy skin catches the dust, the 
face is apt to look dirty. At times the skin of the nose 
may be hyperremic. The forehead is, likewise, a not un- 
common site for this form of seborrhoea. It may occur 
on the scalp, and render the hair unusually oily. It is 
most often noticed when the patient is bald. It is apt to 
cause alopecia. Upon the nose it may occur as the only 
disease of the skin. Upon the forehead and nose it is not 
an unusual accompaniment of acne. Acne and comedones 
may complicate the disease in any location. 



SEBORRHEA. 509 

rrhoea sicca occurs with much greater frequency 
than does the oily form of the disease. We are called 
upon to remove it from all the regions already mentioned 
as the locations for the manifestations of seborrhoea. It 
most usually appears in the form of yellowish or grayish 
fatty plates or masses, which when taken and rubbed be- 
tween the fingers impart a greasy feel. Upon the scalp it 
constitutes one form of dandruff. Here it may be general, 
involving the whole scalp ; or it may locate itself in cer- 
tain places in a mure pronounced way than in others ; or 
it may take the form of rings. The hair is dry, and after 
a time, the seborrhoea continuing, it begins to fall, and at 
last baldness is established. 

In this form of seborrhoea the hairy regions are espe- 
cially affected, and we find it in the eyebrows, bearded 
portions of the face, and the hairy portions of the chest. 
The axillse and pubes are rarely affected. In all these 
places it presents similar appearances — yellowish or gray- 
ish fatty plates. Upon the chest it is not uncommon to 
see the fatty matter in little heaps, piled up, as it were, 
about the mouths of the hair follicles. Close observation 
will show that the follicle mouths are wider open than 
they should be. As in the oily form, the skin feels greasy, 
and acne and comedones may be present. The interscap- 
ular region is frequently affected, and both here and on 
the chest the disease often takes the form of round or 
irregularly shaped patches which look as if they were 
covered with a brownish-yellow varnish. This is the 
seborrhoea corporis of Duhring and the lichen circinatus of 
the older English authors. 

Aside from the appearance of the fatty crusts and a 
slight amount of itching when the patient is warm, this 
form gives rise to no symptoms. When the crusts are 
removed the underlying skin is of normal appearance. It 
may be slightly paler than it should be, but it is never 
moist. What the patient complains most about is that 
flakes from the crusts, becoming loosened, fall upon the 
clothing and make it look as if powdered. If the patient 
happens to be bald, he does not find the yellowish fatty 
crusts upon his bald head desirable. But the most serious 



510 DISEASES OF THE SKIN. 

aspect of the case is that if the disease is not cured it is 
very sure to cause the hair to fall, especially if the patient 
is at all predisposed to baldness. 

There is a second variety of seborrhcea sicca, in which 
a varying amount of dermatitis is added to the seborrhcea. 
Then there will be a rim of redness about the fatty crust, 
and when the crust is removed from the skin the under- 
lying part will be seen to be red. In this variety there 
will be far more decided itching and burning than in the 
preceding variety. It is to be noted that although the 
skin is red, it is always dry and never infiltrated, in these 
respects differing from eczema. 

Upon the nose this variety of seborrheal dermatitis 
forms a yellow plate with a red line about it. At times 
this plate may be extensive enough to cover the whole 
nose. More frequently the disease is limited to the fur- 
rows behind the aloe nasi, and then assumes the form of 
fatty plates upon a good deal of underlying redness. 
The eyebrows and bearded portions of the face are also 
quite commonly affected, but rather as a diffuse redness 
combined with a branny scaling than as a solid plate sur- 
rounded by a red line. 

Besides the regions already mentioned as the usual loca- 
tions of seborrhcea, we meet with the disease also upon the 
ears (in the tragus and behind the ears) and in the anal 
fold. The scalp is, however, by far the most frequent 
location of the disease, and here it may exist alone for 
years. Whenever it exists elsewhere it is sure to be found 
at the same time upon the head. 

In infants the disease is very common, taking the form 
of thick crusts upon the scalp that are often of a dirty- 
gray color. These give the careful mother a good deal of 
annoyance, she being in great dread lest some one should 
think that she is not careful to keep the precious baby 
clean. This form of the disease is usually the remains of 
the vernix caseosa. 

Etiology. The usual etiological factors of seborrhcea, 
as given in the text-books, are debility, chlorosis, consti- 
pation, and a number of other things, indicating that the 
ci mdition of the patient is below par. Of course, the ability 



SEBORRHCEA. 511 

of these to cause seborrhoea is questioned ; but that they 
are quite capable of aggravating the disease I have no 
doubt. The disease affects all classes and conditions of 
men, all ages, and both sexes. 

There are many things that seem to indicate a conta- 
gious element in the etiology of the disease. Cases have 
been reported in which a husband or wife has contracted 
dandruff after marriage, he or she having been, before, free 
from the same. The experiments of Lassar and Bishop 
point in the same direction. They took the scales from 
the head of a student who was losing his hair, and, having 
made a pomade of them with vaseline, rubbed the same 
into the back of a guinea-pig, and the pig became bald. 
Up to two years ago we accepted without question the 
theory that seborrhoea is a functional disease of the seba- 
ceous glands. This is now doubted by some authorities. 
Unna teaches that the process is inflammatory from the 
start, and that the oil that fills the epithelial scales comes 
not from the sebaceous glands, but from the sweat glands. 
What we have called seborrhoea sicca he would have us 
call, for the present at least, seborrheal eczema. (See 
Eczema seborrhoicum.) He regards it also as parasitic. 

In support of his thesis he presents us with microscop- 
ical studies and certain arguments. His work has been 
reviewed by other competent pathologists, and his obser- 
vations have been substantiated by their findings. His 
proposition that the sebaceous glands are not responsible 
for seborrhoea has not been accepted generally. What is 
called seborrhoea oleosa, Unna believes to be nothing more 
than a hyperidrosis, to which he gives the name of hyper- 
idrosis oleosa. This view he must take of necessity, on 
account of his theory of the office of the sweat glands. 

It is affirmed that seborrhoea is due to a micro-organism. 
Brooke, of Manchester, believes that, to the parasite of 
seborrhoea without dermatitis, another parasite adds itself, 
to produce the dermatitis and the ring formation. For 
further information the reader is referred to the article on 
eczema seborrhoicum. 

Diagnosis. The diagnosis of seborrhoea sicca is usu- 
ally easy. It is to be recognized by the presence of fatty 



512 DISEASES OF THE SKIN. 

grayish or yellowish plates or crusts, seated either upon a 
normal or slightly reddened skin. These crusts or plates 
differ from those met with in eczema in being- more readily 
removed, and in imparting to the finger a greasy feel. 
Moreover, the crusts of eczema are of a more solid con- 
sistence, being formed by the drying of an almost muci- 
laginous discharge upon the skin. When eczema occurs 
upon the head the exudation glues the hairs together. In 
seborrhoea the hairs are not glued together, but are dry 
and powdery. In eczema there is more or less itching at 
all times, while in seborrhoea the itching comes on most 
generally when the head is hot, as from artificial lights, 
sweating, and the like. In eczema there is moisture or a 
strong tendency thereto. In seborrhoea moisture is never 
seen. 

Psoriasis is another disease with which seborrhoea sicca 
is apt to be confounded, as it, too, occurs in the form of 
powdery scales and crusts upon the scalp. If a case pre- 
sents itself with these conditions upon the head alone, we 
may be very sure that we have to do with a case of seb- 
orrhoea, as psoriasis rarely exists upon that region alone. 
Seborrhoea usually occurs diffusely, while psoriasis occurs 
in the form of circumscribed patches. The crusts of seb- 
orrhoea are yellowish or grayish, while those of psoriasis 
are of a silvery hue. In some cases, however, seborrhoea 
will occur in circumscribed patches, and the crusts of 
psoriasis may be of a grayish hue. 

When seborrhoea sicca occurs upon the chest and back 
in the form of rings with scaly centers, we have before us 
a more difficult problem in diagnosis. Now we must de- 
cide whether we have to do with a seborrhoea, a ringworm, 
or a pityriasis rosea. The resemblance to ringworm is 
often very striking, but ringworm does not, as a rule, occur 
in so diffuse a manner. If, at the same time with the 
lesion on the chest, Ave find other lesions on the back 
between the shoulder-blades, we may be quite sure that the 
case is one of seborrhoea. Happily in any doubtful case 
we have a sure resort in the microscope. If the case be 
one of ringworm, we will surely find the trichophyton. 
Upon examining the scalp, if the disease be seborrhoea, 



SEBORRHCEA. 513 

we will surely find plain evidence of it there. There 
should be no difficulty in recognizing the presence of a 
ringworm on the scalp. 

In the differential diagnosis from pityriasis rosea we are 
deprived of the kindly aid of the microscope. Here, too, 
the occurrence of seborrhoea on the scalp will aid us in our 
decision. Moreover, pityriasis rosea is generally more 
diffused over the trunk than is seborrhoea, and occurs also 
on the arms and abdomen. By close inspection we may 
trace the development of the disease from its beginning as 
a small red spot through its successive growth into the 
typical oval to annular patch with its withered parchment 
or chamois-leather-like looking center. It is scaly, never 
crusted. In some cases, however, the diagnosis will remain 
somewhat doubtful. 

Treatment. The treatment of seborrhoea is simple. 
It is somewhat in favor of the parasitic theory of the origin 
of the disease that the drugs that are most efficacious in its 
cure are active antiparasitics. In my hands by far the 
most satisfactory remedy has been sulphur. After the 
removal of the crusts by means of any oil or grease (this 
should be done the first thing whatever remedy is chosen), 
the sulphur is to be applied in the strength of a drachm 
of the precipitated sulphur to an ounce of rose ointment. 
It should be well rubbed into the scalp, and the application 
repeated every night for one week. It must be remem- 
bered that the remedy is to be applied to the scalp and not 
to the hair, and that it is necessary to use only a very little 
of the ointment. After one week's use of the sulphur the 
head is to be washed with soap and water, and the oil, or 
salve, immediately reapplied. During the second week it 
will be sufficient to make the application every other night. 
Thus the treatment is to be continued, the number of appli- 
cations being reduced until they are made but once a week. 
By this time the disease will usually be cured. The patient 
is to be cautioned that relapses are likely to occur, and 
therefore it will be best for him to keep a supply of his 
oil, or salve, on hand, so as to attack the trouble as soon 
as it shows itself. 

The objections to sulphur are two : it has a slight odor, 

33 



514 



DISEASES OF THE SKIN. 



and it leaves a slight yellow powder on the sealp. The 
first objection is overcome by the exhibition of the sulphur 
in rose ointment. The second is lessened by cautioning 
the patient not to use the application too freely, and by 
having him wash the head more often. 

The ointment recommended by my distinguished friend, 
Dr. Bronson, is a very elegant as well as efficient substi- 
tute for the sulphur. It is 



R Hydrarg. amnion., T^j— ij ; 5-10 

Hydrarg. chlor. mitis, T^ij— iv ; 10-20 

Vaselini, ad ,^j ; a<l 100 



M. 



This is to be used in the same manner as the sulphur 
ointment. 

"While one or the other of these will bring the case to a 
happy issue, it is well to have a variety of means at com- 
mand. H. Ji. Crocker 1 commends: 



B 



Ac. acetici, 


o s H 


Resorcin., 


3J; 


Aq. cologniensis, 


3u; 


Glycerin i, 


ad gvuj 


Aqua? rosa", 



15-30 

4 

60 

4| 
ul 250 



Some other remedies are salicylic acid in castor oil, three 
per cent, strength; resorcin in oil, diluted alcohol, or vase- 
line in three to ten per cent, strength; or a solution of 
hydrate of chloral, a drachm to the ounce. A favorite 
formula is : 



R Hydrarg. biclilor., 
Resorcin., 
01. ricini, 

Alcoliol., 



ad 



gr. ij ; 

o.i ; 3 

o.i ; 3 

5iv ; ad 100 



This will cause an exfoliation of the scalp in some cases. 

For a soap, both for cleansing and stimulation, nothing 
is better than the tincture of green soap. If the scalp is 
peculiarly irritable, then it is best to use a milder soap, 
such as Pear's glycerin soap. 

The treatment of seborrhoea of the body and face is 
1 Clin. Joiirn. Lond., 1897, x„ p. 81. 



SPIRADENOMA. 515 

upon the same lines as that of the scalp, only that on the 
body we can use an ointment instead of an oil. 

For the seborrhoea of infants usually all that is required 
is to keep the scalp well oiled with olive oil. If this does 
not cure, then a mild sulphur ointment with vaseline may 
be used. 

For seborrhoea oleosa dabbing ether on the part will 
most promptly remove the greasy look. Washing with 
soap and water will act as a stimulant. Powdering with 
sulphur and starch, or using a three per cent, solution of 
resorcin in alcohol and water, will tend to cure. 

In all forms general treatment will be called for if the 
patient is out of tone. General tonic treatment is required 
in nearly all cases of seborrhoea oleosa. 

Under Alopecia furfuracea will be found further direc- 
tions as to the treatment of seborrhoea of the scalp when 
it has led on to baldness. See also Eczema seborrhoicum, 
which is that which I have here described as seborrhoea 
sicca, in deference to the older teachings. 

Prognosis. Seborrhoea oleosa is often recovered from 
when the patient is in good general condition. Seborrhoea 
sicca is usually readily cured, but is very sure to return, so 
that the patient must keep by him for further use any 
remedy he has found efficacious. 

Seborrhoea Congestiva. See Lupus erythematosus. 

Seborrhoea Nigricans. See Chromidrosis. 

Shingles. See Zoster. 

Siderosis. A defacement of the skin due to the entrance 
into it of small particles of iron or steel, producing blue- 
black marks. It is seen in ironworkers. 

Sommersprosse. See Lentigo. 

Spargosis. See Elephantiasis. 

Spedalskhed. See Lepra. 

Sphaceloderma. See Dermatitis gangrenosa. 

Spider Cancer. See Telangiectasis. 

Spiradenoma. See Adenoma of sweat glands. 



516 DISEASES OF THE SKIN. 

Spitzes Condylom. See Verruca and Syphilis. 

Stearrhcea. See Seborrhoea. 

Steatoma. See Sebaceous cyst. 

Steatorrhea. See Seborrhoea. 

Stigmasie sen Stigmata. See Hsematidrosis. 

Stinkschweiss. See Bromidrosis. 

Stonepock. See Acue. 

Striae et Maculae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Strophulus. See Miliaria. 

Strophulus Albidus. See Milium. 

Strophulus Prurigineux (Hardy). See Prurigo. 

Sudamina. See Miliaria. 

Sudatoria. See Hyperidrosis. 

Sudor Urinosus. See Uridrosis. 

Sueurs Color^es. See Chromidrosis. 

Summer Eruption of Hutchinson. See Hydroa vaccini- 
forme. 

Sweating, Excessive. See Hyperidrosis. 

Sycosis. Svnonvms : Sycosis non parasitica; Sycosis 
menti ; Sycosis barbae; Mentagra; Acne mentagra; Fol- 
liculitis barbre; Folliculitis pilorum : Herpes pustulosus 
mentagra; Lichen menti; Acne sycosis; (Fr. ) Sycosis 
non parasitaire ; Dartre pustuleuse mentagre ; Adeno- 
trichie ; (Ger.) Bartfinne, Bartflechte ; Fikosis ; (Eng.) 
Barber's itch. 

An acute or chronic follicular and perifollicular inflam- 
mation of the long hairs, chiefly affecting the bearded 
portions of the face ; characterized by an eruption of 
papules, pustules, and tubercles perforated by hairs; by 
ihe formation of infiltrated patches; and by a greater or 
less amount of crusting. Sometimes the disease is so 
intense as to form abscesses. 



SYCOSIS. 517 

Symptoms. It is only in comparatively recent years 
that this disease has been recognized as a separate entity, 
and it is still regarded by some authorities as merely a 
form of eczema. The disease begins by the formation of 
a number of red inflammatory papules and tubercles which 
are more or less conical, usually raised above the surface 
of the skin, and always perforated by hairs. Their appear- 
ance is preceded and accompanied by disagreeable local 
sensations, such as pricking, burning, and smarting, and at 
times by a feeling of tension in the part on account of 
swelling of the skin. In acute cases there is considerable 
redness of the skin between the papules, and the inflamma- 
tion may be so intense as to give rise to enlargement of the 
neighboring lymphatic glands. The papules and tubercles 
vary in size from that of a millet-seed to that of a pea, and 
are isolated or grouped, not every hair follicle in a diseased 
part being affected by the peri-follicular inflammation. 
Only in very severe outbreaks or in acute exacerbations do 
the papules and tubercles tend to run together and form 
infiltrated patches. 

The papules and tubercles soon change into pustules, 
which preserve the same characteristics of grouping and 
are likewise always pierced by hairs. These pustules, 
conical in shape, and perforated by hairs, are pathogno- 
monic of the disease. In old cases they are met with in 
the infiltrated patches arising apparently without the pre- 
ceding appearance of papules and tubercles. The pustules 
show no tendency to rupture, but the pus accumulates 
below, swells up alongside of the hair, appears upon the 
surface of the skin, and dries into thin crusts. The amount 
of crusting is never very great, far less than in eczema of 
the beard, and is appreciable mainly when the beard is 
growing. If the inflammation is very intense, we may 
meet with small cutaneous abscesses here and there, instead 
of pustules. According to A. R. Robinson, the amount of 
pus-production varies with the individual attacked, being 
more rapid and abundant in the robust than in the scrof- 
ulous ; in acute than in chronic cases. 

The hairs, if of any length, are early affected in appear- 
ance, becoming lusterless. They are at first firmly seated 



518 DISEASES OF THE SKIN. 

in their follicles, and when pulled upon give rise to pain, 
and if extracted their root sheaths will appear as clear 
glassy cylinders. Later, as pus forms more abundantly 
in the peri-follicular tissues, and the follicles themselves 
are involved in the process, the hair becomes loosened 
and easily extracted, when its root sheath will be found 
swollen with pus. If the pus-production is excessive, the 
hairs will fall of themselves or upon the slightest traction. 
When this occurs the hair papilla? may be so damaged 
that no new hairs will form. In chronic cases the board 
is markedly thinned, though permanent loss of hair is the 
exception. 

The disease may attack any part of the bearded face, 
and may be met with in other hairy regions, as the neck, 
the eyebrows, scalp, axilla, and pubes. But the beard is 
by far most often the site of the disease, the other situations 
being aifected in the order in which they are named. 
Occurring in the beard, it may be limited to a single region 
and show no tendency to spread. Thus it is met with very 
frequently upon the upper lip alone, or at times upon the 
cheeks alone. When it affects the upper lip alone it is 
always preceded by nasal catarrh, and takes the form of a 
diffused dermatitis with much thickening of the lip and 
some crusting. It may attack the whole bearded face in 
an acute outbreak, or it may involve it by extension from 
a limited area during a number of successive outbreaks. 
In chronic cases it is usually symmetrical. The course of 
the disease is chronic and made up of a number of acute 
exacerbations. If left to itself, it may produce a good deal 
of deformity, the tubercles and pustules breaking down, 
ulcerating, and leaving cicatricial tissue and more or less 
baldness, though this is exceptional. 

A typical case of sycosis presents the following appear- 
ance : upon a single region, two or more regions, or upon 
the whole bearded portion of the face there will appear a 
number of isolated or grouped papules, tubercles, and pus- 
tules pierced by hairs. The skin about the lesions is red- 
dened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly 



SYCOSIS. 519 

the eyebrows will be similarly affected, and a blepharitis 
will be present. When the case is watched for a time 
marked exacerbations will arise often without apparent 
cause, last for a few days, and then the disease will sink 
into a subacute condition. When the disease affects the 
vibrissa? of the nose, by extension from the upper lip, the 
Schneiderian membrane becomes swollen and exquisitely 
sensitive. The disease tends to run a chronic course, last- 
ing for years. 

Etiology. The etiology of the disease is not settled." 
It is not very common, perhaps one case in three or four 
hundred. It is doubtless contagious in some cases, and 
transferred by the agency of the barber shop. It is seen 
in men almost exclusively, as we might expect, as it is the 
beard that is most often affected ; and attacks them most 
frequently between the ages of twenty-five and fifty. It 
affects all classes and conditions. Most of its subjects are 
in poor general condition. 

Eczema is often a forerunner of sycosis, the one process 
passing over into the other. A nasal catarrh is the cause 
of the majority of cases occurring on the upper lip. Shav- 
ing with a dull razor against a stiff beard is said to be 
sometimes an exciting cause, though those who do not 
shave are by no means exempt from the disease. An 
irritant applied to the skin may excite it, such as exposure 
to intense heat, the dust of a workshop, cosmetics, and the 
like. Exposure to inclement weather is regarded by 
Wilson as the principal cause. One of the worst cases I 
have met with was directly traceable to a poultice applied 
to the face for the relief of a neuralgia. Given a hypersemic 
or irritable condition of the skin of the face, arising from 
any internal or external cause, the hairs, especially if they 
are coarse, may excite the disease, acting as irritants when 
touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed 
the inflammation to irritation of the hair follicle by hairs 
whose diameter was, relatively, too large for their follicles. 
The staphylococcus pyogenes is found in relation with most 
cases of sycosis, but this would prove inoperative unless the 



520 



DISEASES OF THE SKIN. 



soil was in proper condition for its growth. Tominasoli 
has found a bacillus in some cases. 

Pathology. The disease is primarily a peri-folliculitis, 
the hair follicles being affected secondarily, and after them 
the sebaceous glands. 

Diagnosis. The distinguishing characteristic of sycosis 
is the presence of pustules pierced by hairs. It must be 
diagnosed from trichophytosis barbre, eczema barbae, the 
small pustular syphiloderm, acne, and lupus. The differ- 
ential diagnosis of sycosis from trichopliytosis barbce is as 
follows : 



Trichophytosis Barb.e. 

Begins as a snnrfl scaly spot, a super- 
ficial ringworm, and gradually in- 
volves the deeper parts of the hair. 

Has its favorite seat upon the chin 
and the submaxillary region ; rarely 
attacks the upper lip. 



The eruption consists of tubercles and 
nodules which tend to group, and 
are studded with a number of hairs. 
The internodular portions of the 
skin often remain unaffected. 



Is a deep inflammatory process so 
soon as the hairs become affected. 

Hair is diseased primarily, and is 
twisted, split, and broken. May 
readily be removed by slight trac- 
tion and without pain. Its root is 
often dry 

Subjective symptoms slight, may be 
only slight pruritus. 



Patches of ringworm often present on 
other parts of the body, and some- 
times the disease extends upon the 
neck or face. 

Hairs and scales loaded with the tri- 
chophyton fungus. 

Is a progressive disease, and when 
cured not liable to relapse. 



Sycosis. 

Begins suddenly with an outbreak of 
papules which soon become pus- 
tules, each of which at the start in- 
volves a hair. 

Its favorite seat is the upper lip, and 
sometimes it alone is involved. In- 
volves the hairy portions of the face 
more generally, and is often sym- 
metrical. 

The eruption consists of papules and 
pustules, each of which is pierced 
by a single hair, and they show no 
disposition to group, the inter- 
vening skin is generally reddened, 
and may be diffusely infiltrated ; 
and abscesses may form. 

Is a more superficial inflammation. 

Hair diseased secondarily, and comes 
away at first with difficulty, causing 
much pain. Later is easily removed 
and its root is swollen with pus. 

Subjective symptoms of pricking, 
burning, arid tension of the part. 
These are often intense and at- 
tended by swelling of the face. 

Limited in most cases to hairy parts 
of face. No tendency to extend on 
non-hairy parts of face or neck. 

No fungus present. 

The course of the disease made up of 
a number of acute outbreaks. Liable 
to relapse. 



The differential diagnosis from eczema of the beard can- 
not be made with so much certainty, and often we must 
remain for a while in doubt as to the true nature of the 
case. At times sycosis is left by a preceding eczema, and 
we may meet with a case in the transition-stage when a 



SYCOSIS. ,521 

sure diagnosis would, manifestly, be impossible. A typical 
case of pustular eczema is attended by a far greater amount 
of crusting than is sycosis, and the crust is of a more 
greenish or blackish color. Upon removing the crust in 
eczema a moist and oozing surface will be exposed, while 
in sycosis we will do no more than remove the tops from 
a number of pustules. In eczema the pustules break 
down more readily than in sycosis, and they are not so 
accurately located about the hairs. In eczema the whole 
surface of the skin is involved, and the process tends to 
extend upon non-hairy parts of the .face. While excep- 
tionally eczema is confined to the hairy portion of the face, 
this is always so in sycosis. The duration of the disease 
will at times help us to a diagnosis, sycosis being far more 
chronic than is eczema. In syphilis, when the beard is 
involved, we will find pustules upon other portions of the 
body, and the history will help us to a correct conclusion. 
Further, the pustules or papules of syphilis are grouped 
in circles and segments of circles, are of a peculiar color, 
and their development is painless and comparatively slow. 
Acne is scattered about the whole face, and is usually met 
with in young persons. Comedones are present, and the 
papules, pustules, or tubercles have no definite relation to 
the hair. The course and history of lupus are so different 
from those of sycosis that it is hardly possible for them to 
be confused. , In lupus vulgaris we have the characteristic 
brown tubercles, which do not contain pus, are not con- 
fined to the hairy portions of the face^generally begin in 
early life, and tend to ulcerate or to be absorbed and leave 
behind cicatrices. 

Treatment. The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should en- 
deavor to put him in as good a hygienic condition as pos- 
sible. He should be advised against exposing himself to 
dust and wind, and then only with his face powdered or 
protected with ointment, and even against smoking, espe- 
cially in a wind where the smoke blows against the face. 



522 DISEASES OF THE SKIN. 

The proper regulation of the diet is important. Many 
cases will improve if we stop their tea, coffee, hot drinks 
of all sorts, ale, beer, and spirits. If the digestive proc- 
ess seems at all embarrassed, it is well to put the patient 
on a light diet for morning and evening, and direct him 
to take his principal meal at noon, eating meat only at that 
time. Anything that is known to him to be indigestible 
must, of course, be prohibited. In a word, the diet and 
hygiene of the patient should be regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there 
are much swelling and inflammation, a good dose of blue 
pill, calomel, or some other active cathartic is to be 
ordered, to be followed by an alkaline diuretic. When 
pustulation is active the sulphide of calcium or calx 
sulphurata may do good. Pitfard recommends this very 
highly, giving one-tenth of a grain two or three times a 
day. 

Small doses of calomel, one-tenth of a grain, three 
times a day, for two or three days at a time, are useful in 
relieving the congestion of the skin. In chronic cases 
iron, cod-liver oil, and other tonies are indicated if there 
is a state of debility. Arsenic is advised in very obsti- 
nate cases. If indigestion is present, we must address 
our remedies to its relief before we give calcium, arsenic, 
or other remedy for the disease proper, and then we will 
probably have no need of so-called specifies. 

The local treatment must vary with the condition found, 
whether it be acute or subacute, and is more important 
than the general treatment. When the disease attacks 
the upper lip the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped upon the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the 
use of a simple oil, such as olive oil or sweet almond oil ; 
or if the face is shaved, the zinc oxide ointmeut or cold 
cream may be used; or better still, Lassar's paste, as 
follows : 



SYCOSIS. 523 

R ^y}' 1 ' .,. \ aa 3 ij; aa 8 

Zinci oxidi, J ° •> ' 

Vaselini, ad ^j ; ad 32 

Powdering the part with cornstarch, or bismuth and 
talc, after smearing on a little vaseline, will at times give 
ease and comfort. 

In the early stage, if the inflammatory symptoms are 
not very intense, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing the face with "black wash," followed by zinc oxide 
ointment with a drachm of alcohol or half a drachm of 
camphor to the ounce, spread on cloths and bound on ; 
and speaks well of the oxide of zinc ointment with fifteen 
to thirty grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 
by the free use of olive oil, or oil of sweet almonds with 
two per cent, of salicylic acid, letting it soak in thor- 
oughly over night and washing the part with soap and 
warm water the next morning. If the crusts are thick, 
it is a good plan to tie up the bearded face in a towel after 
anointing it with oil. After the crusts are gotten rid of, 
the hairs should be pulled out of the pustules and epila- 
tion continued until pustules cease to form. The patient 
must be made to understand that epilation is necessary 
both for the cure of the affection and the salvation of the 
hair. After epilating, the oxide of zinc ointment, Lassar's 
paste, or diachylon ointment is to be used. Shaving is 
recommended, but it seems to me better to content our- 
selves with cutting the hair short. Shaving is apt to 
irritate the skin, and certainly would favor the dissemina- 
tion of the pus organisms. Sulphur in the form of an 
ointment, half a drachm to a drachm to the ounce, or in 
powder, will sometimes do good, but often will prove too 
irritating. Tilbury Fox recommends the use of the fol- 
lowing ointment after epilating : 



R Zinci oxidi, < _-- , 



Zinci carbonat., J ^ ' 

Ungt. aq. rosse, ad 5J ; ad 32| M. 



524 DISEASES OF THE SKTN. 

Instead of an ointment we may use oxide of zinc, one 
drachm to the ounce of linseed or other oil. Shoemaker 
advises the application of equal parts of oleate of mercury 
and olive oil. 

In subacute and chronic cases a more active treatment 
is necessary. Here our aim is not so much to allay in- 
flammation as to stimulate the skin. To this end we may 
use the soap and salve treatment of Hebra, which renders 
such good service in chronic cases of eczema. (See page 
202.) In some cases better results will be attained by 
the use of diachylon ointment, or Lassar's paste with ten 
or fifteen grains of salicylic acid to the ounce. In very 
obstinate cases in which there is much thickening of the 
skin green soap may be kept applied to the part like an 
ointment. When sufficient inflammatory reaction is pro- 
duced emollient measures, as in the acute stage, should 
be used. 

Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and 
the dressings must be kept continuously in close contact 
with the affected part. Sometimes a sulphur ointment, 
one-half a drachm to two drachms to the ounce; an oint- 
ment of iodide of sulphur ; the ointment of the ammoniate 
(gr. xv-xxx ad 5J) or the nitrate (sj-ij ad =j), or the red 
oxide (gr. v-xv ad sj) of mercury will prove useful. 
Robinson recommends the following ointment : 

K Ungt. diachyli (Hebra), ) -- -. -. 4R | 

Ungt. zinci oxidi, / a,l <i lbS ' ddAb 

Ungt. hydrarg. amnion, giij ; L2 

Bismuth, subnitrat., o>ss; G M. 

He has found cod-liver oil the best local application in 
strumous subjects. 

Behrend has obtained good results by scraping the affected 
parts with the dermal curette and dressing with a simple 
ointment or oil. All abscesses must be opened. In some 
cases the following ointment has given me satisfaction after 
other combinations have failed : 



SYPHILIS. 525 

R Hydrarg. snlph. rubri, gr. vij ; 

Sulph. sublimat., ,^iij ; 12 

Adipis, 5iss ; ad 50 

01. bergamot., q. s. ; q. s. M. 

To be kept on constantly. 

Solutions of the bichloride of mercury, 1 : 1000 ; or of 
resorcin in alcohol five per cent, strength, after shaving, 
may be used. 

Kaposi recommends the following : 

R 



/J-naphtol., 

Spt. sapo. viridis, 

Alcobolis, 


gr. xv. ; 

5. v J » 

5iss ; 


1 

25 
50 


Bals. peruv., 
Sulph. loti, 


3iiss ; 


2 

10 



The ammonio-sulphate of ichthyol and other drugs used 
by cataphoresis are commended. 

Boric acid, salicylic acid, and numerous other remedies 
seem to do good in some cases. To assure against a relapse 
it is necessary to continue making applications to the skin 
for four or five months after apparent recovery. 

Prognosis. This is one of the most obstinate of dis- 
eases. Left to itself, when once under headway it shows 
no tendency to get well, and has been known to last twenty 
or thirty years. Even under the most judicious treatment 
it is an obstinate disease, taking weeks or months before a 
cure is effected. Relapses are exceedingly liable to occur, 
and these sometimes show a disposition to recur at certain 
seasons. Unless the hair is carefully plucked from the 
inflamed follicles permanent baldness may be caused. But 
the disease is not dangerous to life, and it is curable. 

Sycosis Contagiosa. See Trichophytosis barbae. 

Sycosis Capillitii seu Framboesia. See Dermatitis papil- 
laris capillitii. 

Sycosis Parasitica. See Trichophytosis barbae. 

Syphilis. 1 Synonyms : Malum venereum ; Lues ; Morbus 

1 In the description of the syphilides I have followed very closely 
those given by Prof. G. H. Fox in his Photographic Illustrations of Skin 
Diseases, Treat, New York; and by Prof. R. W. Taylor in his Pathol ogy 
and Treatment of Venereal Diseases, Lea Brothers & Co., Philadelphia. 
To both of these gentlemen I would extend my grateful thanks for 
the permission to use their books that was granted to me. 



526 DISEASES OF THE SKIN. 

Gallicus, seu Italicus, seu Hispanicus, seu Neapolitanus, 
seu Indicus ; (Fr.) Yerole, or Grosse verole ; (Ger.) Lust- 
seuche ; (Eng.) Bad disorder, Pox. 

AVhole books have been written upon this disease. 
Here we can give only a brief outline of the disease, and 
that as it affects the skin alone. For a further account 
of the disease the reader should consult the larger special 
treatises. 

Symptoms. Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 
which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably ninety per 
cent, of the cases this initial lesion is located on the geni- 
tals, and in the vast majority of these its site in males is 
the glans and prepuce. But the initial lesion may be 
found on any part of the body, and within the mucous 
cavities. According to a table of one hundred and ninety- 
eight extra-genital lesions compiled by Pospelow, 1 the 
female breasts Mere affected in sixty-nine eases ; the lips in 
forty-nine cases ; the throat in forty-six cases ; and then in 
very much less frequency the gums, tongue, chin, eyelids, 
n<>-c, trunk, anus, arms, and legs. Some obscure cases of 
syphilis are due to the initial lesion being in the urethra 
or upon the cervix uteri or deep in the throat, and thus 
escaping detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison ; usually the interval 
is less than four weeks ; exceptionally it may be ten weeks. 
This is the period of incubation. Opinions are divided as 
to whether the initial lesion is a purely localized lesion or 
the expression of a general constitutional infection that 
first declares itself at the point of inoculation. It appears 
to me that the weight of the argument is altogether on 
the side of the last opinion. The initial lesion may assume 
the form of a scaly patch, a dry or moist papule, a super- 
ficial erosion, or a circumscribed ulcer with perpendicular 
edge. Induration of the base is a characteristic of all 
forms of initial lesion ; it is sharply defined and imparts 
to the fingers a distinct resistance that may be as firm as 
1 Arch. f. Dermat. u. Syph., 1889, xxi., 59. 



SYPHILIS. 527 

cartilage. Commonly it is parchment-like. To detect it, 
the lesion must be gently pinched between the thumb and 
linger. It is present coincidently with the appearance of 
the initial lesion or within a few days afterward. It 
remains for a long time after the disappearance of the 
lesion — for two or three months or longer. The secretion 
from the initial lesion, when present, is thin and chiefly 
serous. The duration of the lesion is variable ; it may 
disappear before the outbreak of cutaneous symptoms, but 
very often remains for some time after this event. Unless 
there has been ulceration, no cicatrix will be left. It may 
leave a staining of the skin or an induration. It is usually 
a solitary lesion, though it may be multiple. Enlargement 
of the nearest lymphatic glands accompanies the initial 
lesion. If on the external genitals, it will be those of one 
or both groins. They become hard, and are painless and 
freely movable. Suppuration is rare, and probably the 
result of mixed infection. A pleiad of glands, three ar- 
ranged in a triangle, is quite characteristic of syphilitic 
infection. In women initial lesions are often so small and 
last so short a time that they are not noticed. In them 
induration is often not noticeable, and the diagnosis is much 
more difficult than in men. They are found on the exter- 
nal genitals, within the vagina, and on the cervix uteri. 

The initial lesion may at first assume the character of 
the soft sore. This is the result of mixed infection with 
both the virus of syphilis and of the local venereal ulcer. 
The ulcer will after a while become indurated and assume 
its proper characteristics. It is in these cases that a sup- 
purating adenitis may develop. Modifications from loca- 
tion of the initial lesion must also be noted. 1. Of the 
urethra. A chancre may be at the meatus, in the fossa 
navicularis, or deeper parts. At the meatus it attracts at- 
tention by causing a slight impediment to urination. The 
lips are found glued together by a scanty, viscid secretion. 
The normal opening of the urethra becomes lessened by the 
induration, which usually involves the entire circumference 
of the meatus. If located deeper down, it may give rise 
not only to interference with urination, but also tp some 
pain, and later to a muco-purulent or purulent discharge 



528 DISEASES OF THE SKIN. 

like that of gonorrhoea, because it causes a urethritis. 
It may be felt as a hard, tender, circumscribed nodule, 
and be seen, with the endoscope, as a grayish-red erosion of 
the urethral wall. It may give rise to symptoms of strict- 
ure. 2. Of the anus. A chancre may be without the 
anus, at its margin, or within the anal ring, and usually 
presents a thickened, fissured, ulcerated surface. It is of a 
pale-rose tint, and decidedly indurated. 3. Of the fingers. 1 
An initial lesion may be seated at any part of the phalanges, 
but most often at the sides or base of the nail, or at its 
free margin. It begins as a papule, pustule, excoriation, or 
fissure, and attracts attention as an obstinate hang-nail or 
fissure ; or as an irregular, deep-red, somewhat elevated 
mass that is ulcerated and covered with a scanty serous 
secretion. The finger is apt to be swollen at its end. 
The epitrochlear and axillary ganglia are enlarged, and 
there may be moderate lymphangitis. 4. Of the lips. 
This chancre is usually covered with a greenish-brown 
crust, which, when removed, leaves either an erosion of 
little, if any, hardness, or an ulceration of cartilaginous 
consistence. It may begin as a fissure or painful excoria- 
tion. The lips may be greatly swollen. Either the upper 
or lower one may be affected ; usually only one. The 
submaxillary glands on the side of the lesion are commonly 
first affected. 5. Of the 1o)i</\te. Here we meet with a 
hard, circumscribed, Mat, slightly elevated, dull-red, smooth, 
pea-sized nodule; or a round, sharply defined, fleshy red, 
raised, hard ulcer. The cervical and submaxillary glands 
arc enlarged. 6. Of the throat. The patient first notices 
difficulty or pain in swallowing, the latter in the region 
of the tonsils. Then the submaxillary and cervical glands 
become swollen. Examination shows an intense, limited 
or diffused, general or unilateral, brown or dark redness 
of the pharynx. The tonsils are enlarged, hard, and red, 
and may be eroded, and perhaps covered with an ash- 
colored deposit — a false membrane. Or we may find an 
irregular, hard ulcer with gna wed-out edges, and, it may be, 
crater-shaped floor covered with dirty-brown or grayish 

1 An admirable study of these lesions by Dr. R. W. Taylor will be 
found in the Medical Record, 1891, xxxix., 69. 



SYPHILIS. 529 

deposit. One or both tonsils may be affected. 7. Of the 
nipple. Chancres of the nipple are usually multiple, and 
may take the form of an erosion, a scaly patch, or an in- 
durated fissure. The size varies from that of a lentil up 
even to three inches in diameter. They are sometimes 
linear, sometimes sickle-shaped along one side of the nipple, 
and sometimes completely encircle the nipple. The nipple 
is red or dark red, enlarged, hardened, and at times flat- 
tened. Mastitis may complicate matters. The axillary 
glands are enlarged, as are often those along the upper 
edge of the pectoralis major. On healing, the initial lesion 
leaves a flattening of the nipple, and perhaps a leaning 
of it to one side, characteristics that should put us on 
our guard in the examination of wet-nurses. 

About six weeks after the appearance of the initial lesion 
(it may be as early as the twenty-fifth day, or as late as 
the one hundred and sixtieth), we have the stage of erup- 
tion of the so-called secondary syphilicles. Usually just 
before the outbreak of the eruption, or shortly after it, 
examination will show a general enlargement of the lym- 
phatic glands, especially the epitrochlear and post-cervical. 
At the time of the eruption, or shortly before, the patient 
may experience certain constitutional disturbances, such as 
severe headache, malaise, pains in the joints, and a rise of 
temperature of moderate extent. In very many cases 
these disturbances either do not exist, or are of so slight 
severity as not to attract the patient's notice. In some 
cases a more or less profound anaemia will manifest itself, 
or the patient will fall into a markedly cachectic condition. 
Either of these may last far into the secondary period of 
the disease. Weakly individuals are more prone to these 
severe constitutional derangements than are the robust, 
and Fournier teaches that they are most apt to appear in 
women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides ; or the early and late lesions. No 
hard-and-fast lines can be drawn, as sometimes those 
lesions usually seen late in the disease manifest themselves 
early in its course. The secondary syphilides are those 

34 



530 DISEASES OF THE SKIS. 

that develop during the first two years after infection. 
They are marked by a mure or less general and symmet- 
rical dissemination over the whole cutaneous surface ; by 
polymorphism; by running a rather definite course; by 
implicating the more superficial parts of the skin and 
mucous membranes : and by leaving little, if any, trace of 
themselves. In these respects they differ from the lesions 
of late syphilis, which are grouped and limited to certain 
regions, are not polymorphic, show less tendency to run 
a definite course, involve the deeper structures, and are 
prone to leave permanent scars. 

The eruptions of secondary syphilis are the erythema- 
tous, the papular, and the pustular syphilide. The first 
eruption of the secondary stage is usually an erythema- 
tous one, the macular syphilide, or the syphilitic roseola. 
Unlike other syphilides, which are all largely composed of 
new cell-growth, this may he a hyperaemia without cell- 
infiltration. It may be a general eruption, though usually 
most marked upon the trunk and flexor aspect of the 
limbs. The macules are about the side of a ten-cent 
piece, or smaller, of a faint rose-red color, circular in form, 
and little if at all raised above the skin. At times we 
meet with annular lesions from disappearance of the 
center of the macule. The lesions, excepting in relapsing 
eruptions, are distinct from each other. They become 
more evident on exposure to cold, it being no uncommon 
thing to see them appear upon the patient's body while he 
is before us stripped for examination. After being out for 
a time their color becomes purplish red, changing to a 
tawny or yellowish red, and later to a brownish yellow. 
In their early stage they can be made to disappear on 
pressure. They either disappear and leave either no trace 
or some pigmentation, or they develop into papules. They 
often coexist with papules and pustules. The evolution of 
this eruption usually requires a week or ten day- ; some- 
times it may be much less. The duration of the eruption 
is from one to three months if not removed by treatment. 
Relapses occasionally occur, and these may be met with as 
late as the end of the first year. Then it is usually 
limited to certain regions. It gives rise to no incon- 



SYPHILIS. . 531 

venience, and is often overlooked by the patient except 
when it appears on the face or hands. At this time there 
are apt to be an erythematous condition of the pharynx, 
some sore-throat, a rheumatoid affection of the joints, 
falling of the hair, and, perhaps, an iritis, and mucous 
patches in the mouth, upon the vulva, in the groin, upon 
the scrotum and under surface of the penis, and about 
the anus. 

While the diagnosis is easy, if we have seen the patient 
from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin ; an 
exanthem ; a medicinal eruption ; chromophytosis ; and, if 
we have annular macules, trichophytosis corporis. From 
mottling of the skin it is diagnosed by the fact that in 
syphilis we have macules of a reddish tint interspersed 
with skin of normal hue, while in mottling we have light 
macules with dull purplish-red interspaces. From an 
exanthematous fever it is diagnosed by the absence of 
catarrhal or gastric symptoms and marked pyrexia, and by 
the sluggish character of its lesions. From a medicinal 
eruption it is diagnosed by an absence of gastric disturb- 
ance, and by its lesions lacking the urticarial or oedematous 
character. From chromophytosis it differs in having a 
red rather than a cafe-au-lait color, by not being scaly nor 
capable of removal by scraping, by its more extensive dis- 
tribution, and by the absence of the microsporon furfur 
from the scales when they are examined under the micro- 
scope. From trichophytosis it differs in the greater extent 
of its distribution, and in the absence of the trichophyton 
fungus from scales scraped from the skin. From pityri- 
asis rosea the differentiation is sometimes difficult when the 
syphilitic macules have assumed a ring-form. As a rule, 
there is no difficulty, as a pityriasis rosea will be scaly, and 
will present not only rings, but macules of all sizes, while 
the syphilitic macules are not scaly and are of more 
uniform size. 

The papular syphilide, while usually following the ery- 
thematous syphilide, may be the first eruption of the dis- 
ease. Indeed, a great many cases begin as a maculo- 
papular eruption. The papules may develop from macules 



532 DISEASES OF THE SKIN. 

or may appear as papules. Very commonly both macules 
and papules will be present at the same time. If it fol- 
lows the macular form, it is apt to appear while the 
latter is fading. The eruption consists of a greater or less 
number of firm, rounded, fleshy-red elevations of the skin, 
varying in size from that of a pinhead to one inch in 
diameter. After continuing unchanged for a certain time 
they undergo absorption ; the oldest or central part of the 
papule disappears first, sinks in a little, and becomes scaly. 
It is then that slight pruritus may be complained of. 
They are scattered over the whole cutaneous surface, and 
often appear in well-marked groups. They are prone to 
relapses, and sometimes are seen as a relapsing eruption in 
the tertiary stage of the disease, when they do not occur 
as a general eruption, but in groups upon one or more 
regions of the body. According to their size, they have 
received the names of the lenticular and miliary papular 
svphilide, the former being the larger and most common 
eruption. 

The lenticular papular syphilide is a hemispherical or 
flattened, firm, fleshy, lentil- to split-pea-sized promi- 
nence with a smooth and glossy surface. Not infrequently 
the superficial layer of epidermis over it is wanting from 
the central portion and slightly detached around the 
base, forming a fringe called the collarette of Biett. 
This is regarded as a diagnostic symptom. The color 
of the papule is at first light red ; later it assumes a raw- 
ham color that is best seen on the legs. From the knee 
down it may have a purplish or hemorrhagic appear- 
ance. Such papules are usually present in great number 
and scattered over the whole body. On the face they are 
apt to locate along the hair-line on the forehead, forming 
the corona veneris. On the scalp they are not very 
numerous, and are apt to become papulo-pustules and 
crust ; or they itch slightly and are scratched. The palms 
and solts are usually well covered in any general outbreak 
of them. Here they appear as reddish spots under the 
thick epidermis. Desquamation is often seen over the 
papules on the palms and soles. Sometimes the eruption 
is very slight in extent, only a few scattered papules being 



SYPHILIS. 533 

found. This syphilid© develops slowly, runs a course of 
one or two months, and disappears, leaving pigmentation 
or slightly depressed spots, neither of which is permanent. 
In undergoing resolution the papules may become scaly 
and form a papulosquamous syphilide, or pustules may 
form on them during their course, and we then have the 
papulo-pustular syphilide. 




••; 



Scaling papular syphilide. (After Lassar.) 

While the form of the lenticular syphilide just described 
is the typical one, we see at times larger papules, from three- 
eighths to half an inch in diameter, forming the large, flat 
papular syphilide. This rarely, if ever, is a general erup- 
tion, but is limited to certain regions. It may occur 
alone or with the lenticular syphilide. It usually follows 
the latter or appears when it is fading. It frequently 
comes as a relapsing syphilide, and often appears late in 
the second year. It has a flattened surface and a circular 



534 



DISEASES OF THE SKIN. 



outline. The lesions often coalesce and form patches 
which frequently become scaly and resemble psoriasis. 
The scaling is never very great ; the scales are thin and 
adherent, and do not cover the whole patch. They fre- 
quently occur upon the flexor aspect of the extremities 
and in the bends of the joints. Instead of forming 
patches by coalescence, the individual papule may enlarge 
at the circumference and become depressed at the center 
and form circinate lesions, whose surface may become 
moist. 

The moist papule or mucous patch is a modified form of 
the lenticular papule, and is simply a papule subject to 




Condylomata lata. (After Taylor.) 



heat and moisture. It is found where two folds of skin 
rub together, as in the peno-scrotal fold, between the 
scrotum and inside of the thigh, around the anus and 
vulva, and upon mucous membranes. It is of circular 
shape and has a flattened surface which is sometimes de- 
pressed in the center. Newly formed ones have a bright- 
red or raw appearance, but they soon become covered with 
a dirty whitish coating made up of thickened and softened 
epidermis. About the anus and vulva they form large 
flattened tubercles called condylomata lata. (Fig. 68.) 
They give forth a most offensive odor when not kept 
clean. When in the mouth they form " opaline patches," 



SYPHILIS. 535 

looking as if the mucous membrane had been pencilled 
with nitrate of silver. They are usually not elevated. 
If at the angle of the mouth, they are generally fissured. 
The mucous patch is one of the most contagious of syph- 
ilitic lesions, the evidence of infection being an initial 
lesion of syphilis, and not a mucous patch. It is also 
at times, especially when it comes late in the disease, 
most obstinate to treatment, and inclined to relapse. 

The miliary 'papular syphilide is much rarer than the 
other form of papular syphilide ; in fact, it is one of the 
least common of the syphilides. The eruption consists of 
numerous pinhead- or slightly larger sized conical papules 
of a purplish-red hue, either disseminated over the whole 
body or aggregated in groups forming circles or segments of 
circles. They are developed about the hair follicles and 
have depressed centers. Many of them may be surmounted 
by a small vesicle or vesico-pustule. This constitutes what 
has been named the vesicular syphilide. Sometimes the 
lesions when closely pressed into patches may be scaly. It 
may be an early lesion or a relapsing later one. In the 
latter case the eruption is not abundant, but in groups. The 
color is brownish red, and pigmentation and permanent 
pitting are left by the lesions, if they have lasted any time. 
They rarely change into condylomata. Their evolution 
is rapid, being fully developed within two weeks. Pea- 
sized conical papules sometimes are seen among the mili- 
ary ones. 

The diagnosis of the papular forms of syphilis is gener- 
ally easy because other symptoms of the disease will be 
sure to be present and to establish the diagnosis. It is 
possible that error may arise in distinguishing the patches 
of scaling papules from jisoriasis, but here the location of 
the patches upon the flexor surfaces of the extremities, and 
over the bends of the elbows ; the scaling not being com- 
mensurate with the patch, but having a red, sharply de- 
fined border about it ; and the well-marked infiltration of 
the patches, are all features that would throw out the 
diagnosis of psoriasis. The miliary papular syphilide 
may be confounded with lichen planus or keratosis pilaris, 
but the absence of itching is always in favor of a syphilide ; 



536 DISEASES OF THE SKIX. 

and the conical or rounded shape of its papules is in strong 
contrast with the flat, angular, and umbilicated papule of 
lichen planus. The syphilid* is also a much more widely 
disseminated eruption than is lichen planus or keratosis 
pilaris likely to be, and is never seen confined to the 
anterior face of the wrists as is lichen planus. 

The pustular syphilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 
always evidence of a poor condition of the health of the 
patient who bears it. It may be the first eruption of 
syphilis, or follow the erythematous or papular form, or 
occur later. It may develop from a macular or papular 
syphilide, or occur with either of them. It may occur as 
a relapsing eruption late in the tertiary period. It is held 
by some authorities that it is always the product of infec- 
tion of a syphilide by pus-organisms. The appearance of 
this form of syphilide is not infrequently accompanied by 
fever. It may assume varying forms and sizes, to which 
in the faulty nomenclature of the older writers have been 
given the names of non-specific lesions, greatly to the con- 
fusion of the student. Dr. George H. Fox has done 
well in discarding all such terms, and in describing two 
forms, the lenticular and the miliary pustular syphilide. 

The lenticular pustular syphilide (variola-form) occurs 
as a disseminated eruption of small, hemispherical, pea- 
sized pustules, having a hard, papular base and more or 
less of an inflamed areola. It may develop by the soft- 
ening of a papule or be a papulo-pustule from the 
start. In the latter case its outbreak will be marked by 
fever, which is apt to recur with each succeeding outbreak. 
The eruption may be general or upon certain regions. 
The lesions are discrete, and do not form marked groups, 
although in the pustular eruptions, as in others, it is easy 
for one who looks for them to find groupings in circles 
and segments of circles. A few days after they appear 
they begin to desiccate, and the larger ones may umbili- 
cate. At this stage they become crusted with a dirty- 
yellow, brownish, or greenish-brown crust. This falls 
soon and leaves a transient pitting and pigmentation. 
Relapses may occur. 



SYPHILIS. 537 

The miliary 'pustular syphilid e (acne -form). This erup- 
tion consists of millet-seed- to pinhead-sized acuminate pus- 
tules developing generally from papules and occurring in 
small groups of about the size of a quarter- or half-dollar. 
It may occur as a general eruption, but is apt to be more 
marked and lasting on the extremities than on the trunK. 
The lesions, especially when occurring upon the flexor 
aspect of the joints, are liable to coalesce. They are devel- 
oped in and around the hair follicles, and may be perfo- 
rated by hairs. They are topped with small crusts. The 
eruption lasts two or three months by the outbreak of new 
lesions, unless controlled by treatment. It leaves pigmen- 
tation and pitting that may remain for several months. 

While these are the two chief varieties of the early 
pustular syphilide, there is another variety that is called 
the impetigo-form syphilide, which occurs most commonly in 
the middle or latter part of the first year of syphilis. It 
may occur as late as in the third year. In it the pustules 
are small and flat, and by confluence an impetiginous crust 
is produced. They may form patches with crusting only 
at the border. This form is met with usually on the face, 
arms, and thighs. A few superficial ecthymatous lesions 
may develop, but ecthymatous lesions are usually late 
manifestations. 

The diagnosis of the pustular syphilide is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola, or varioloid. 
It differs from these in the infiltrated bases of the pustules, 
in being composed of lesions of varying size and age, in 
not occurring in the mouth, and in not running a definite 
rapid course. The miliary form might be mistaken for 
acne, but it is never confined to the face, chest, and back 
as is acne, nor does it present comedones, and so great 
multiformity of lesions. 

Tertiary Syphilides. The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis and during the first year. As 
we have seen, they may also constitute relapsing eruptions 
later in the disease. Modifications of them may occur 
late in the secondary period or even in the tertiary period. 



538 DISEASES OF THE SKIX. 

Besides these, we have a second group of syphilides that 
occur any time after the first year, and sometimes as late 
as twenty or more years after the initial lesion, when the 
patient may have lost all remembrance of it. To these 
eruptions the name of tertiary or late syphilides is given. 
Their peculiarities have been indicated in a general way 

Fig. 69. 




Annular tubercular syphilids. (After Taylor 



when writing of the early syphilides. They are the tu- 
bercular, the squamous, the pustulo-crustaceous, the gum- 
matous, and the ulcerative syphilides. Exceptionally 
these eruptions may occur before the second year, when 
they are to be regarded as precocious lesions. 

The tubercular syphilide occurs in the latter part of the 



SYPHILIS. 539 

second year of syphilis, or later. Exceptionally it may 
occur during the first year as a so-called precocious syph- 
ilide. As a rule, the early syphilides cease appearing 
after six or seven months, and then after a varying inter- 
val of rest the late lesions appear. These may never 
come at all, usually as the result of judicious treatment, 
or it may be because of the vigorous resistance of the 
constitution of the individual. Tubercular lesions occur 
in the form of clustered nodules in the deeper part of the 
corium. At first they are of faint-red color; gradually 
they become a dull red, and later still darker. In size 
they vary from that of a split pea to that of a hazelnut, 
and constitute firm, elastic, fleshy protuberances. They 
are round, smooth, and somewhat glossy, or flat, rugous, 
and withered. They are frequently scaly. Most often 
they are arranged in circles or segments of circles ; or 
they may be in the form of rings from the first, or in con- 
sequence of the disappearance of the central members of 
the group. (Fig. 69.) There may be but a single group ; 
or numerous groups may be scattered over the body in a 
symmetrical manner. A very frequent location for them 
is the posterior portion of the neck or on the face. The 
later in the course of the disease they occur, the more 
they are apt to form but a single group. If uninfluenced 
by treatment, tubercles may continue to form for years, 
the old ones disappearing and new ones coming. They 
disappear either by absorption, or by softening or break- 
ing down and forming a sharply cut ulcer with perpen- 
dicular edges and yellow sloughing base. A number of 
the lesions breaking down at once and coalescing, a large 
ulcer with scalloped border, indicating its composition 
from single lesions, and with more or less thick greenish 
crust, will form. In either case they leave depressed, 
smooth cicatrices, at first pigmented, but later white. 
They give rise to no subjective disturbances. Rarely do 
they form a general eruption. 

The diagnosis of this form of syphilide is usually read- 
ily arrived at by finding other symptoms of syphilis. Oc- 
casionally it may be confounded with lupus vulgaris and 
leprosy. From lupus it is differentiated by the compara- 



540 DISEASES OF THE SKIN. 

the rapidity of its course, lupus being- a disease of exceed- 
ing slowness of development ; by its occurrence in mature 
years, lupus being a disease of youth; by its sharp-cut 
round ulcers ; by its thick greenish crusts, and by the 
smoothness of its cicatrices, those of lupus being puckered 
and deforming. Syphilis at times bears a striking re- 
semblance to leprosy when its tubercles are located in the 
eyebrows, face, and ears, but the absence of anaesthesia is a 

Fig. 70. 

ffr 



I 






Squamous serpiginous syphilide. (After Lassar.) 

positive diagnostic sign against leprosy. Moreover, other 
symptoms of leprosy, such as swelling of the ulnar nerves 
and peculiar brown patches, will be absent. 

The squamous syphilide is not usually described, as it is 
a modified form of either the papularor the tubercular lesion. 
In using the term here, I follow Dr. George H. Fox, 
and like him adopt it purely on clinical grounds. He 
applies the term to scaly patches of circular or irregular 
form that occur after the first year of syphilis. These 



SYPHILIS. 541 

patches are covered with thin horny scales seated upon an 
infiltrated base. We may have one of two forms : the 
discoid or the circinate. The discoid form is almost pecu- 
liar to the palms and soles and neighboring parts, and 
constitutes the only apparent lesion. The round patch 
of varying size, but with a sharply defined reddish seam 
beyond the scaling, and an infiltrated base, tends to be- 
come serpiginous, creeping over a considerable portion of 
the skin. Sometimes while it advances at one border it 
heals at the other; at other times it clears up in the center, 
leaving an elevated, scaling marginal ring. The ring may 
be broken and leave a curved line, and if two or more of 
these lines meet, we have a gyrate figure. Usually but 
one palm or sole is involved. The skin is apt to crack in 
the natural creases, and then the patient will suffer some 
pain and discomfort. It is always an obstinate lesion to 
cure, persisting sometimes for months or years. The 
circinate form differs from the just-described one in being 
annular from the first, and in occurring not only on the 
palms and soles, but elsewhere on the body. 

The diagnosis of this form of syphilide from a squam- 
ous eczema of the palm is often one of great difficulty. 
The fact that only one palm is affected is always suggestive 
of syphilis. Moreover, in syphilis there are more infiltra- 
tion and much less itching. Indeed, the latter may be 
entirely absent. In syphilis the lesion is often crescentic, 
with sound skin between the horns of the crescent. This 
is never seen in eczema. Psoriasis of the palm is in most 
cases not to be thought of as a stumbling-block in diag- 
nosis, as it is exceedingly rare for psoriasis to affect the 
palms, and then only as a part of a general outbreak of 
the disease. Some writers use the term syphilitic psoriasis 
for the scaly palmar syphilide, but it is a most faulty 
method of nomenclature. 

The pushdo-crustaceous syphilide is characterized by 
large and usually deep-seated pustules or ulcers, covered 
by prominent and peculiar crusts. It is the eefhyma-form 
of R. W. Taylor and other authorities. It occurs as a late 
and localized form of the disease ; never as a general erup- 



542 DISEASES OF THE SKIN. 

tion. It may occur as a precocious syphilide. It is seen in 
debilitated subjects, and is of gradual development, without 
febrile symptoms as in the pustular syphilide. It has 
preference for the scalp, face, and extremities. It assumes 
three forms, the ecthymatous, rupial, and pemphigoid. 

The echtkymatous form begins as an eruption of one or 
more round, flat pustules of a diameter of one-quarter to 
one-half inch. Tluy may become as large as a silver half- 
dollar. They have a well-marked inflammatory areola and 
a swollen and indurated base. The pus soon dries and 
forms a flat, greenish or brownish-black crust, whose cen- 
ter is sometimes depressed. At first the crust fully covers 
the pustule, but later, either through drying or on account 
of an increase in the size of the pustule, a raw rim is left 
around it. When it is now removed it exposes a typical 
punched-out ulcer with its base covered with sanious pus, 
which rapidly dries into a new crust. Under proper treat- 
ment the pustule heals, and when the crust falls there will 
be left a healed or nearly healed ulcer. A permanent 
cicatrix is left when healing is completed, which is smooth 
and white eventually. This syphilide is seen most often 
on the legs and arms. If the course of the disease is not 
checked, the crust is cast off by increased suppuration, and 
the ulcerative syphilide is before us. 

The second variety of the pustulo-crustaceous syphilide 
is that which is commonly known as rupia. It differs 
from the preceding variety in being more superficial at 
the beginning, and in forming a conical, laminated crust 
somewhat resembling an oyster shell. It begins either 
as a superficial pustule or as a small flattened bulla with no 
inflammatory induration. Upon the primary lesion a 
greenish crust develops, under which ulceration, with 
suppuration, occurs. The margin of the ulceration ex- 
tends a little beyond the original crust. A new crust 
forms upon it, raising up the original one, and this process 
being repeated, at last a laminated crust is raised. When 
the ulceration extends more rapidly in one direction than 
another it follows that the crust will be higher at one 
end than at the other. Crusts may form a half-inch or 
more in height, and one or two inches in diameter. If 



SYPHILIS. 543 

the lesions are numerous, they are usually small ; if few, 
large. When these thick conical crusts are removed, the 
ulcer is exposed and is less deep than in the ecthymatous 
form. On healing, a permanent, smooth, white cicatrix is 
left at last. 

The third variety of the pustulo-crustaceous syphilide is 
the pemphigoid or bullous form. It is a very rare lesion in 
acquired syphilis, though quite common in hereditary dis- 
ease. It consists in an eruption of superficial, purulent, 
flattened bulla? from one to five centimeters in diameter, 
which tend to dry into thick crusts. They are surrounded 
by a dull-red areola, and are soon covered by dark green- 
ish-black adherent crusts. If the patient be in fair 
health, the ulceration under the crusts will not be deep. 
If the patient be a broken-down subject, the ulceration 
may be very deep. It will leave either a pigmented 
atrophic spot or a pronounced scar, according to the depth 
of the ulceration. 

The diagnosis of the pustulo-crustaceous syphilide is 
usually easy if the disease is known to the observer, as 
no non-specific disease resembles it closely. The so-called 
ecthyma cachedicum is more inflammatory than is the 
ecthymatous syphilide, and more superficial. The bullous 
syphilide often bears a striking resemblance to pemphigus, 
and can be diagnosed only by a study of all the features 
of the case. 

The gummous syphilide is perhaps one of the most char- 
acteristic of the late lesions of syphilis. It consists in a 
deposit of gummy material in the skin. The distinction 
between some tubercular lesions and a gumma is often 
very indistinct, and made principally by the size. The 
gumma begins in the subcutaneous tissue and involves the 
skin secondarily. It may take the form of a single tumor, 
a group of nodules, or a diffused infiltrated patch. It is 
nearly always a late lesion, and while it may undergo 
absorption it possesses a strong tendency to break down 
and ulcerate. (Fig. 71.) 

The single tumor begins as a small pea-sized nodule, 
seated in the subcutaneous tissues so deeply as to be ap- 



544 DISEASES OF THE SKIN. 

predated only by the touch. It grows slowly ; in the 
course of weeks or months it may attain the size of a nut 
and push up the skin over it into an evident tumor, 
which is movable, firm, elastic, painless, and rolls under 
the finger. Increasing in size, it involves the skin, which 
then becomes of a dull-reddish color. When the skin 
becomes involved the tumor is no longer movable, and 
soon fluctuation may be felt that would lead the inexpe- 
rienced to open it as an abscess. If he did so, it would 

Fig. 71. 




Gummata. (After Jullien.) 

be a mistake. He woidd find only a little pus, a gummy 
substance, and some blood. Left to itself, the tumor may 
be absorbed, or it may break down and ulcerate, leaving 
a characteristic deep and round ulcer. The scalp and 
forehead are the chosen sites for this syphilide, though it 
may occur anywhere. It sometimes attains a large size 
— as large as a hen's egg. When this lesion occurs as 
a precocious syphilide it is usually of small size and 
multiple. 



SYPHILIS. 545 

When gumraata occur in the form of grouped nodules 
the skin between them is apt to become infiltrated with a 
gummatous deposit, and the patch will present the dull 
brownish-red color of the late syphilides. The individual 
members of the group run a course similar to that of the 
isolated gumma, but do not attain its size. When they 
break down they form a large irregular ulcer. This 
variety of the gumma is frequently met with upon the 
scalp, the nose, the outer aspects of the extremities about 
the joints, and around the lower portion of the leg and 
ankle. Diffuse gummatous infiltration of the skin prob- 
ably precedes all serpiginous ulcerations. Apart from this 
it is rarely seen, and almost always ends in ulceration. 

Other gummatous deposits are known as syphilitic dac- 
tylitis, admirably described by R. W. Taylor, and syphilitic 
bursitis, carefully studied by E. L. Keyes. One being a bony 
and the other a synovial disease, they do not here concern us. 

The diagnosis of the gumma must be made with care. 
It may simulate other forms of tumors. It is not as hard 
as the sarcoma, nor as compressible as the lipoma, and it 
invades the skin. An abscess is usually attended by pain 
and signs of inflammation, and runs a more acute course 
than does the gumma. 

The ulcerative sypkilide, according to Dr. George H. 
Fox, merits being described by itself, though in itself only 
a sequence of a tubercular, pustulo-crustaceous, or gumma- 
tous syphilide, because in the majority of cases of 
syphilitic ulcers met with it is hard or impossible for 
us to say what the preceding lesion has been. For con- 
venience, he describes the superficial, the serpiginous, and 
the deep or perforating forms of syphilitic ulceration. 

The superficial syphilitic ulcer is circular, with sharply 
cut edges and dirty-yellowish purulent base. It most often 
follows a pustular or pustulo-crustaceous lesion, and may 
appear comparatively early in the disease, especially in 
debilitated subjects. It is usually of the size of a quarter- 
or half-dollar, and frequently coalesces with other ulcers to 
form ulcerative patches with scalloped margins. The face 
and legs are its most common sites. 

35 



546 DISEASES OF THE SKIN. 

The serpiginous ulcer is so called because it tends to 
creep over the surface, healing by a cicatrix as it passes 
along. It may develop from a single circular ulcer heal- 
ing in the middle and at one side, and leaving a crescentic 
or "horseshoe" ulcer at the other side, with a sharp 
convex margin, beyond which is a narrow zone of infil- 
tration upon which the ulceration constantly encroaches, 
while healing at its concave border. Or a group of 
crusted pustules or softening tubercles form a number of 
small round ulcers, of which the outer ones usually form 
a curving line. While those in the center and at one 
side tend to heal, new lesions develop at the periphery 
of the opposite side, which ulcerate and perhaps coalesce, 
and so the disease creeps on. This form is often observed 
upon the back and on the extremities; it is not par- 
ticularly painful, and the patient's health may not be 
impaired. 

The deep ulcerations of syphilis result, for the most part, 
from the breaking down of gummatous deposits. The 
small ones are crater-like in shape. Often the opening of 
the softened tumor is smaller than the softened mass, and 
it is not infrequent to find the cavities of adjacent tumors 
running together subcutaneouslv. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific 
ulcers is most important from a therapeutical standpoint. 
A chronic ulcer located anywhere above the middle half 
of the leg is in most cases syphilitic. If it is not, it is 
probably either traumatic, tubercular, or cancerous. The 
traumatic ulcer is acute and highly inflammatory ; of 
irregular shape ; has a history of traumatism ; and heals 
rapidly, excepting in very broken-down subjects, under 
simple dressings. The tubercular ulcer, if from broken- 
down caseous glands, has a history of the previous glan- 
dular affection; is irregular in shape; often presents a 
number of sinuses and ridges of inflamed tissues ; and 
runs a sluggish course. If it is a lupous ulcer, there will 
be found somewhere in the neighborhood the characteristic 
apple-jelly-like tubercles; there will be a history of com- 



SYPHILIS. 547 

rnencing in early life ; the edges of the ulcer will be shelv- 
ing or undermined ; and there will usually be more or less 
deforming cicatrices present. A cancerous ulcer, usually 
an epithelioma, will have a history of beginning in a 
pimple, wart, mole, or such like ; will be irregular in 
shape with an uneven floor ; will be apt to be attended 
by lancinating pain ; will usually be a single lesion, located 
on the face ; and will have a raised, waxy, rolled-out border 
over which delicate blood vessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irreg- 
ular in shape with shelving edges, rather superficial, sur- 
rounded by a brawny, infiltrated, brownish or dark-red 
tissue with more or less scaling, and there are varicose 
veins above it, we have to do with the so-called varicose 
ulcer. This is in sharp contrast with the round or scal- 
loped bordered, deep, punched-out ulcer with perpendicular 
edges and greenish base, around which there is but a small 
zone of redness. The diagnosis of syphilis is strengthened 
when we find a number of ulcers, or the cicatrices of old 
ulcers. As a rule the syphilitic ulcer is located on the 
posterior surface of the upper half of the leg, while the 
varicose ulcer is on the anterior surface of the lower third 
of the leg. The diagnosis from a traumatic ulcer has 
already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation fol- 
lowing a syphilide, which is sufficiently common, and due 
to a staining of the skin with hsematin, but a true pig- 
mentation without antecedent lesion, which is sometimes 
seen on the sides of the neck, especially in women. It is 
composed of irregularly round or oval spots, one-eighth of 
an inch to one inch in diameter, with ill-defined margins, 
and cafe-au-lait color, which does not fade on pressure. 
The color may be very faint. The lesions may be discrete 
or confluent. When they are very numerous they have 
been compared by Fournier to a "network of lace with 
large meshes." This is one of the rarer manifestations of 
syphilis. 



548 DISEASES OF THE SKIN. 

General Diagnosis of Syphilis. Having now 
studied briefly the various cutaneous lesions of syphilis, 
we are prepared to state those general features of the 
syphilides that serve to distinguish them from other dis- 
eases of the skin. 

One marked feature of them is that they do not itch. 
Itching does occasionally occur with the scaling papular 
syphilide, and in some cases the patient will complain of 
an itching of the skin that is quite independent of syphilis, 
but in themselves they do not itch. 

The early eruptions of syphilis are general and exhibit 
a marked polymorphism, many different lesions being 
often present at the same time; as, for instance, macules, 
papules, and pustules. The late eruptions exhibit a strong 
tendency to grouping of the lesions in circles and segments 
of circle-. 

The color of the lesions is peculiar, and perhaps may be 
best. described as that of raw ham, though the classic term 
is "copper." This color is by no means always present. 
It is not seen in the early bloom of the early lesions, but 
is pretty sure to be found in those that have existed for 
some time, and in the late lesions. The color of a lesion 
on the legs, it must be remembered, must not be regarded 
for purposes of diagnosis; it is upon the arms, face, trunk, 
and thighs that we must look. 

Painlessness is often a suggestive symptom pointing 
toward syphilis when we have to decide as to the nature 
of an ulceration. 

It is well not to lay too much stress upon the history of 
the case in making up our mind as to a late syphilide, 
because with the best intentions the patient may forget 
having had an insignificant initial lesion some twenty, or 
perhaps thirty, years before. 

Space will not permit of our here detailing the differ- 
ential diagnosis between syphilis and the many diseases 
which it may simulate from time to time. For this the 
reader must be referred to the sections upon eczema, 
psoriasis, lupus, alopecia, etc. 

Etiology. That acquired syphilis is due to contagion 
we know. Further than this we know little of certainty. 



SYPHILIS. 549 

Various attempts have been made to prove its bacillary 
origin, by Lustgarten and others, but at present the best 
authorities are by no means agreed upon the correctness of 
this theory. 1 We can, in the meantime, speak of its being 
due to a specific virus. The microbial! theory is also ap- 
plied to all pustular syphilicles, and we are taught that 
they are the result of an infection of the specific lesion by 
the pus-coccus. 

Pathology. Syphilis is a new cell infiltration which 
always breaks down. The macular syphilide is the only 
one that does not show this infiltration until perhaps late 
in its course. 

Hereditary Syphilis. Before entering upon the study of 
the treatment of syphilis, we must stop a while to consider 
hereditary syphilis. This differs from the acquired form 
in having no initial lesion, the disease being acquired in 
utero from either one or both parents. We cannot enter 
upon a discussion of the many conflicting theories as to 
whether or not the child is diseased on account of spring- 
ing from a diseased ovum, or spermatozoa; or the possi- 
bility of the disease, acquired by the mother after her 
pregnancy, reaching the foetus through the placental cir- 
culation ; or like interesting questions over which the battle 
rages. For us now it suffices to make the bald statement 
that the disease may be acquired from one or both parents. 
It is most sure to be acquired from the mother, and it may 
be inherited by the foetus from a mother infected some 
months after conception. It is possible for a woman to 
show no signs herself of syphilis, and yet to give birth to 
a syphilitic child. It is exceedingly rare for the appar- 
ently healthy mother of a child hereditarily syphilitic to 
be infected by it. As a result of syphilitic infection in 
utero, the child may be born prematurely, and dead; it 
may be born at term, dead, and showing specific lesions ; 
or it may be born alive with some syphilitic eruption ; or, 
as is commonly the case, the eruption may not appear 
before the second or third week. Miller, 2 from a study of 

1 For a good study of the probable origin of syphilis consult Finger, 
Arch. f. Dermat. u. Svph., 1890, p. 331. 

2 Jahrb. der Kinderheilkunde, 1888, xxvii., Heft 4. 



550 DISEASES OF THE SKIN. 

one thousand cases of congenital syphilis in a foundling 
hospital in Moscow, found that the first appearance of the 
disease was in the first month of life in sixty-four per cent, 
of the cases ; and in the second month in twenty-two per 
cent. In congenital syphilis there is a marked absence of 
that sequence of events more or less observed in acquired 
syphilis, but the diagnosis is usually quite as easy. The 
earliest eruption to appear, as to point of time, is, accord- 
ing to Miller, the bullous syphilide, which he met with 
in twenty-five per cent, of the cases. One of the earliest 
and most characteristic symptom of hereditary syphilis is 
"snuffles," due to an ozsena, which gives the child great 
discomfort by interfering with breathing and nursing. 

The erythematous syphilide is, according to Taylor, the 
most frequent and earliest eruption ; according to Miller, 
it occurs in but forty-five per cent, of the cases. It begins 
on the lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide 
in children is seen upon the inside of the thighs, about 
the anus, and on the buttocks, and may extend down to 
the feet. It is patchy in character, the patches being 
either of small size, or large by the coalescence of several 
smaller ones. It diifers from intertrigo in its patchy 
character, in its darker color, and in its wider distribu- 
tion. 

The papular syphilide and its modified forms of the 
mucous patch and condylomata lata are common con- 
genital lesions. The lenticular syphilide, large and small, 
is met with far more frequently than the miliary papular 
syphilide. It is usually a symmetrical and general erup- 
tion. It may be smooth or scaly, and always has the raw- 
ham color. Mucous patches are very often at the junction 
of the mucous membrane and the skin, as on the lips or 
anal orifice. The movements of the parts will give rise to 
painful fissures — rhagades — which constitute a sign of 
hereditary syphilis as characteristic as the "snuffles/' 
These rhagades Miller met with in seventy per cent, of his 



SYPHILIS. 551 

cases. Mucous patches also occur in the cavity of the 
mouth. Condylomata lata occur where two skin surfaces 
rub together, and especially where there is more or less 
moisture, as about the anus and genitals, in the groins and 
axillae, and between the fingers and toes. Their color is 
usually grayish pink to dark brown; their size varies 
greatly, and their surface is flat, or fissured and ulcerated, 
and exudes an offensive secretion. They are character- 
istically located when at the angles of the mouth, in com- 
bination with mucous patches in the mouth with rhagades 
between. 

The pustular syphilide may be general, but is usually 
most pronounced on the thighs, buttocks, and fj;ce. It 
shows a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but 
usually not till late in the disease. 

The vesicular syphilide is a rare form of early congenital 
syphilis of severe type. It is never general, but appears 
as groups of closely packed together vesicles upon the 
chin, about the mouth, or on the nates, forearms, hypo- 
gastrium, or thighs. They are seated upon infiltrated, 
brownish-red bases. The larger vesicles may be seated 
upon papules. This eruption is apt to be associated with 
a pustular or bullous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. 
Miller found it in twenty-five per cent, of his cases. It 
frequently exists at birth or as the earliest syphilide, and 
is indicative of a severe form. It is most commonly seen 
on the palms and soles, which are often covered with the 
lesions, while few, if any, are on the trunk. The face is 
a favorite location for the eruption. The bullae are either 
tense or flaccid, and at first have sero-purulent contents 
that soon become purulent. They are seated upon a raw- 
ham colored infiltrated base. Hemorrhage into them not 
infrequently occurs. When they rupture or dry up they 
exhibit an unhealthy-looking ulceration that soon becomes 
covered with a greenish crust. Some of them may dry 
up with little, if any, ulceration. It rarely relapses. It 



552 DISEASES OF THE SKIN. 

differs from pemphigus in occurring upon the palms and 
soles, while sparing the trunk, and in the profound ca- 
chexia and the presence of other signs of syphilis. 

The tubercular syphilide is not common, and is always a 
late lesion. While it may be seen as early as the sixth 
month, it is more apt to occur much later as a relapsing 
syphilide. In appearance and course it resembles the 
same lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation of 
the disease, and is sometimes met with in early adult life 
as a lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish red, 
dry, shiny, and fissured. 

Besides the skin-lesions the infant bears certain unmis- 
takable signs of syphilis. It has a marked pallor, and, 
no matter how blooming it may appear at first, it soon 
loses flesh and assumes " an old man " countenance. It 
has a characteristic, hoarse, toneless cry, which once heard 
will be remembered. Its hair is scanty, its nose is apt 
to be flattened, and altogether it is a most woebegone- 
looking object. The skin eruptions usually occur within 
the first six months of life, and if the child can be brought 
through that period it may suffer no more. Nevertheless, 
congenital syphilis, like the acquired disease, may be latent 
for years, to crop out once more. The victims of congen- 
ital syphilis sometimes show the notched or peg-shaped 
teeth regarded by Hutchinson as a certain sign of the dis- 
ease. (Fig. 72.) This appearance is presented by the 
second set of teeth only, and is not absolutely diagnostic, 
as the same has been met with in scrofula. The two mid- 
dle upper incisors are those which are depended on for 
diagnosis. "They are small, often converging, some- 
times diverging. The cutting-edge of the teeth is some- 
times narrowed, rounded off. They are stunted and badly 
developed, often marked with seams in front, and of a 
dirty-brownish color, but their chief peculiarity is found 
in their edges, which, being thin when cut, break off cen- 
trally, leaving a broad, shallow, vertical notch on the lower 



SYPHILIS. 



553 



border of the tooth." (Keyes.) The syphilitic child is 
subject to diseases of the bones, one of the most charac- 
teristic of which is dactylitis. Space will not permit of a 

Fig. 72. 




mm 
iijmg 



Hutchinson's teeth. 

detailed description of the bone and other lesions apart 
from those of the skin. 

Treatment. The treatment of syphilis is by the use 
of both constitutional and local remedies, and by a con- 
stant and long-continued watchfulness on the part of the 
physician over the patient's hygiene and general well- 




Dactylitis. (After Bergh.) 



being. One chief obstacle to the successful treatment of 
a case is the patient's lack of faith in his physician. Most 
patients, just as soon as the eruption for which they sought 



554 DISEASES OF THE SKIN. 

advice fades away, will cease coming to the physician, 
and will pay little heed to his warning, that unless they 
keep themselves under medical supervision for three or 
four years they will be liable to serious trouble later on. 
Nevertheless, our first duty is so to instruct them. Then, 
before putting the patient upon a regular course of treat- 
ment, we should give him careful directions as to his 
exercise, liberal diet, and bathing, and should stop his 
alcohol, insist upon his taking plenty of sleep, and giving 
up the use of tobacco. This last is not only to put him 
in better condition, but also to prevent mucous patches in 
the mouth. The patient should be cautioned against 
drinking out of public drinking-cups, and apprised of the 
danger of infecting others by means of table utensils, 
pipes, and the like. Now he is ready for his course of 
treatment. 

Constitutional Treatment. The drugs employed and 
found of value in syphilis are chiefly but two, namely, 
mercury and iodine in combination with sodium or potas- 
sium. These drugs are given in varying combination, 
and during varying periods, according to the views of 
different physicians. Mercury is the remedy relied on 
most for combating the disease, and should be used under 
ordinary circumstances by itself alone during the first 
year or two of the disease. The iodides exercise a marked 
control over the ulcerative syphilides, and in the late or 
precocious manifestations of the disease. By some they 
are given continuously or as the sole remedy in late 
syphilis, but the best practice is in favor of their adminis- 
tration either with mercury or instead of mercury for a 
short time. Treatment should be begun as soon as we 
are sure that the patient has syphilis. As an element of 
doubt may often enter into our diagnosis of the initial 
lesion, it is a good general rule not to administer specific 
treatment until the appearance of some secondary symp- 
tom. This plan has the additional advantage of producing 
a moral effect upon the patient, who, if he sees an erup- 
tion upon himself, will be more apt to believe that he has 
syphilis, and to submit himself to a thorough course of 
treatment. 



SYPHILIS. 555 

We will consider first the treatment of early syphilis 
and the use of mercury. This drug, regarded by the 
majority of physicians as the sheet-anchor in the treat- 
ment of syphilis, is administered, for its constitutional 
effect, by the mouth, by inunction, by fumigation, and by 
hypodermic injection. 

Of these different methods, the most frequently em- 
ployed is the first — that is, by the mouth. The salt of 
mercury that I most frequently use is the protiodide, 
otherwise called the green iodide. This may be exhibited 
either in pill, tablet triturate, or granule ; and as the tab- 
let triturate is easily obtainable, very reliable, and quite 
inexpensive, my preference is for that preparation. Keyes 
prefers the granules of French manufacture, and says that 
the very objection raised by many authorities to the use 
of the protiodide, namely, its irritant effect on the intes- 
tinal tract, is its shining virtue, because instead of giving 
warning of intoxication by causing salivation, it does so 
by causing diarrhoea. The dose to begin with should be 
from one-sixth to one-fifth of a grain three times a day 
after meals, and the number of pills increased every third 
or fourth day until there is a little " colicky diarrhoea." 
The dosage should be then continued at the same number 
of pills, until the symptoms are controlled. Then we 
can reduce it to half the number. It may be necessary to 
give a little opium at the same time with the mercury, in 
order to control the diarrhoea if it is deemed advisable to 
continue at the point of full tolerance, and this not only 
with the protiodide, but with other salts. Practically the 
daily dose of the protiodide may be put at four or five of 
the one-fifth grain tablets, and three or four of the quarter- 
grain ones, and opium is rarely called for. 

Many prefer to use metallic mercury in the form of 
hydrargyrum cum creta, or calomel in the dose of one or 
two grains two or three times a day after meals, increased 
every three or four days sufficiently to influence the erup- 
tion. Salivation is, in the general run of cases, to be 
avoided. Some authorities prefer to combine a tonic with 
the mercury. Taylor gives the following : 



556 DISEASES OF THE SKIX. 



B Hydrarg. protiodid., 
Ferri et quininte citrat., 
Ext. hyoscyami, 

Ft. pil. No. xxx. 


gr. viij-x ; 
3iss; 
gr- vj ; 


6 


52-65 
39 M. 


B Hydrarg. tannici, 
Quin. sulphat., 

Ext. hyoseyami, 
Ft. pil. No. xxx. 


gr. xv-xxx ; 

si; 

gr. vj ; 


1-2 
4 


39 M. 



In severe cases in which it is necessary to get the 
patient rapidly under the influence of mercury, calomel 
in one-tenth grain doses in the form of tablet triturates 
may be given every hour until the gums become tender. 
Then the calomel should be stopped and the treatment 
continued with a small dose of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of g 3 ^ to^of a grain in solution. It 
is usually given in compound syrup (if sarsaparilla or some 
bitter infusion. The most common mode of administer- 
ing it is in combination with the iodide of potassium, the 
so-called mixed treatment, the formula for which will be 
given later when speaking of the treatment of late 
syphilis. The best opinion is in favor of reserving the 
use of iodine until the early stage is passed. The tan- 
nate of mercury is well spoken of in the dose of half a 
grain. Space will not allow of mentioning the other salts 
of mercury that have been recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously for from four to six months. 

Where practicable the use of mercury by inunction is 
the speediest and best way of getting the patient under 
the influence of the drug. It may be used from the first 
or at any time during the course of the disease. Its great 
advantages are the promptness with which it acts and the 
sparing of the stomach and intestinal tract. Its great 
disadvantages are that it is a dirty method, impracticable 
with most patients, as it attracts notice from his friends 
and attendants ; and the difficulty encountered in getting 
the patient to carry out the treatment with thoroughness. 
It is admirable for hospital treatment. The patient is to 



SYPHILIS. 557 

be told to rub into his skin, once a day, a piece of ungt. 
hydrarg. cinereum, or an ointment made with lanolin as a 
base, of the size of a hazelnut — from half a drachm to one 
drachm. He is to divide the mass into two equal parts, and 
work it in with the heel of his hand for about fifteen min- 
utes while he sits before a fire or in a warm room. Before 
beginning the inunctions he is to take a warm bath, or to 
bathe the parts about to be rubbed, so as to open the pores 
of the skin. The first day he is to rub the ointment into 
the bends of both elbows ; the second day, over the sides of 
the chest ; the third day, over the abdomen ; the fourth 
day, inside of the thighs ; and the fifth day, behind the 
knees — that is, he is to choose the parts least covered 
with hair ; and to change the sites of the inunctions, so as 
to avoid setting up a mercurial eczema. On the sixth 
day he is to take another bath, and on the seventh day to 
resume the inunctions. The treatment is to be pursued 
until active symptoms of the disease are overcome, when 
all treatment may be suspended. A thorough course of 
from eighty to a hundred inunctions is said to be often fol- 
lowed by a permanent cure. If the inunctions are to be 
made by an attendant, he should wear a stout rubber glove. 
As a substitute for inunctions, E. Welander l proposes 
spreading about a drachm and a half of mercurial oint- 
ment on the inside of a small pillow tick, and having the 
patient wear this, properly fastened, next the skin over the 
anterior plane of the body, day and night. This plan of 
treatment is good only in slight cases. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus and 
a great amount of time and trouble. It is said to be a very 
efficient method, specially useful in bad cases and where 
prompt results must be attained. From one-half to one 
drachm of calomel, metallic mercury, or other salt of mer- 
cury, is vaporized by means of the special apparatus, the 
naked patient sitting over it enclosed in a cabinet or 
blankets, out of which only his head protrudes. Each 
bath lasts ten minutes, and it is repeated every second 
day. 

1 Arch. f. Dermat. u. Syph., 1897, xl., 257. 



558 DISEASES OF THE SKIN. 

The hypodermic injection method of administering mer- 
cury, or rather the deep intramuscular method, was first 
advocated by Scarenzio in 1854, and of late years has been 
much experimented with. The injections are usually made 
deep down in the gluteal region, behind and above the 
great trochanter. They are usually painful ; often followed 
by abscesses ; require daily or frequent visits to the physi- 
cian's office ; and do not seem to be followed by sufficiently 
lasting effects to warrant their frequent employment. They 
are useful where we wish to have a very prompt effect from 
the mercury, as in a malignant precocious case of syphilis ; 
or where the stomach must be spared ; or where the disease 
has not yielded to the ordinary plans of treatment. Pa- 
tients in this country seem to object very strongly to their 
employment. A great number of salts of mercury and 
combinations have been introduced, each one of which has 
been found by its introducer the best and most reliable. 
An admirable study of them will be found in Hare's Sys- 
tem of Therapeutics, vol. ii.,by Prof. R. W. Taylor. Here 
we can indicate, and briefly, but a few. Taylor gives one 
of corrosive sublimate, gr. xl ; glycerin, ."j ; distilled water, 
."iij, of which twelve drops are used at each injection. The 
albuminate of mercury, dose fifteen minims ; the formamide 
(Liebreich), dose one-half to a whole Pravaz syringeful of 
a one per cent, solution ; calomel, one part, to liquid vase- 
line, twelve parts, dose a half Pravaz syringeful once a 
week; "gray oil," composed of twenty parts of pure mer- 
cury, forty of liquid vaseline, and five of ethereal tincture 
of benzoin, dose one-third of a syringeful every ninth 
day ; ' the salicylate, fifteen grains to six ounces of water 
and many others. A final judgment as to the comparative 
merits of the many salts cannot yet be given. 

Late Syphilis. If a patient who has not been under 
systematic treatment comes to us with a late syphilide, the 
so-called mixed treatment will be most appropriate to his 
case. As usually administered it is made up according to 
one of the following formulas : 

1 Leloir and Tavemier : Giorn. Ital. d. Mai. Yen. e del Pelle, 1889, 
xxiv., 247. 



SYPHILIS. 559 

06-12 



R Hydrarg. bichlor. vel \ o .... 

Hydrarg. biniodidi, J & • J J i 

Potass, iodidi, 3J _ 'j ; 4-8 



Inf. gentian, co. vel \ 

Syr. sarsaparillse co., 



ad giv ; ad 120 

Dose : A teaspoonful three times a day after meals. 



Or, 



U Hydrarg. biniodidi, gr. ss-ij ; 03-12 

Amnion, iodidi, ^ss; 2 

Potass, iodidi, Sij-^j 5 8 ~ 32 

Syr. aurant. cort., gjss ; 45 

Tr. aurant. cort., 3j ; 4 

Aqua?, q. s. ad §iij; ad 100 M. 

Dose : A teaspoonful in water, three times a day. (Keyes.) 

If a patient comes to us with a gumma, an ulcerative 
syphilide, a group of serpiginous tubercular sypli Hides of 
the tertiary period ; or if any of these or other deep lesions 
threatening destruction of tissue appear early in a case of 
precocious or malignant syphilis ; or if the disease attacks 
the nervous system, the larynx, pharynx, or eye — in fact, at 
any time when there is need of prompt effects, we must 
administer the iodides. If he has had no mercury for some 
time, it is best to give it to him now either by the mouth, 
mixed treatment, or inunctions, while the iodide is admin- 
istered separately but at the same time. The iodide of 
potassium is most generally used, and next to it the iodide 
of sodium. There is no set dose for the iodide. It is best 
given in a dose of five grains in solution in water, three 
times a day, before meals, diluted in milk, or Vichy, or 
soda-water ; or some three hours after meals. Delavan l 
has found that the iodide can be given most satisfactorily 
by putting five drops of a saturated solution in the bottom 
of a small tumbler, with fifteen drops of essence of pepsin, 
and pouring upon it two ounces of warm milk. This is be 
set away in a cool place, and will form a rennet custard, 
which can be easily swallowed. This is a good method 
when we wish to give nourishment with the medicine or 
when the throat is sore. The mixture can be given a 
pleasant taste by adding a teaspoonful of sherry wine. 

The dose of the iodide should be increased by one or 
J Med, Rec, 1891, xl., 651. 



560 DISEASES OF THE SKIS. 

two drops each day — that is, six drops t. i. d. ; then seven 
drops t. i. d., and so on, until the nose runs and the eyes 
water, or some symptom of iodism develops. The most 
convenient method of administration is to have a solution 
made containing one grain of the iodide to each drop of the 
solution, so that every drop represents a grain. Most 
patients bear iodine well, but in some even drop doses 
produce iodism. Iodic acne is very often induced, but 
should not cause us to stop using the drug. It is advis- 
able to suspend the administration of the iodides from 
time to time, and to give mercury, which, after all, must 
be depended on for curing syphilis. 

Now and again we will meet with cases that do not 
improve under either mercury or iodine, but relapse and 
relapse, or remain stationary. Such cases should be sent 
mit of town, ordered change of air for a time, and put on 
a purely tonic course of treatment. Very often when the 
patient returns home he can take his medication easily, 
and the previously obstinate lesions will yield readily. 
This is but what we said at first ; the patient's general 
condition must all the time be carefully watched over. 

Salivation is an unpleasant accident that may occur 
under the use of either mercury or iodine. At one time it 
was quite common — indeed, mercury was purposely pushed 
so far as " to touch the gums," and, of course, this was 
often overdone. Its symptoms are tenderness of the teeth, 
so that pain is felt when the jaws are snapped together ; 
the gums are swollen ; there is a metallic taste in the 
mouth ; a fetid odor of the breath ; increased flow of saliva 
by day and night; all the mucous membranes of the 
mouth are swollen, so much so as to interfere with mastica- 
tion and deglutition, and in very bad cases there may be 
ulceration, loosening and fall of the teeth, and caries of the 
bones. 

Prevention is always better than cure, and to this end 
we should see that our patient's teeth are in good order 
before beginning treatment, and direct him to wash his 
mouth frequently with chlorate of potash solution, ten or 
fifteen grains to the ounce, or one of alum, and to keep 
his teeth clean. The patient should be seen frequently at 



SYPHILIS. 561 

first, so as to stop the mercury before salivation attains 
any serious degree. Salivation having begun, the mercury 
must be stopped, and the potash solution in same strength 
may be continued, and one or two drachms of it swal- 
lowed during the day. The compressed tablets are 
useful. Dilute Labarraque's solution, or solutions of per- 
manganate of potash or other astringent, may be used for 
a gargle and mouth-wash. A laxative should be admin- 
istered, the patient kept warm in bed, and, if necessary, 
an anodyne given. 

Duration of mercurial treatment. How long the patient 
should take mercury is a question, the answer to which is 
very variously given by different authorities. Keyes puts 
it at from eighteen months to four years. Taylor says " at 
least two years to two years and a half, counting from the 
date of the commencement," but he advocates intermis- 
sions of from two to three months, iodide of potassium 
being given in the meantime. Schwimmer ' advocates 
giving mercury for two or three months, and then one of 
the iodides for two months ; after four or five months of 
treatment making a pause of two or three months, treat- 
ing any local lesion locally, and then repeating the course. 
Fournier 2 usually administers mercury for six to nine 
weeks ; then pauses six weeks ; then gives another six 
weeks' medication. During the first year he puts the 
patient through four courses ; during the second year, 
three courses ; and during the third year, two courses. 
During the fourth year he gives the iodide alone for six 
weeks, with corresponding intervals. Crocker advises 
stopping mercury about every six weeks to give the iodide 
for a week or ten days. At the end of six months, if the 
patient has been free from symptoms for two or three 
months, a month's pause may be made, to be followed by 
a six weeks' course of mercury. And so through the first 
year. During the second year he alternates a six weeks' 
mild mercurial course with a one or two weeks' course of 
the iodide. If still free from lesions, treatment may be 
suspended until some symptom crops out. 

1 Second Supplement to the Monatshefte f. prakt. Dermat., 1888. 

2 Gaz. des Hop., 1889, No. 103. 

36 



562 DISEASES OF THE SKIN. 

Against these advocates of long-continued mercurial 
treatment there are others, no less eminent, who advocate 
the administration of mercury only during the duration of 
the symptoms, and for a few months afterward ; then they 
advise to suspend all treatment until some new outbreak 
of the disease calls for it. In combating so insidious a 
disease as syphilis, it seems to me wisest to err rather on 
the side of too long continued treatment than on that of a 
too short course. 

Local Treatment. While internal treatment by 
mercury and the iodides is quite competent to remove the 
syphilodermata, their disappearance can be materially 
hastened by local treatment by means of mercurial appli- 
cations. Ointments of metallic mercury, of the ara- 
moniate, the red oxide, and the oleate, with solutions of 
the bichlorides, are the preparations most generally em- 
ployed. 

Many attempts have been made to abort syphilis by 
excision of the initial lesion, or its destruction by means of 
caustics. These have been failures in most instances. 
This is not to be wondered at in the light of R. \V. 
Taylor's recent studies, 1 which show that " in the very 
first days of syphilitic infection the poison is deeply rooted 
beneath the initial lesion, and extends far beyond it, 
infecting all the parts beyond, even to the root of the 
penis." The initial lesion should be dressed with iodoform 
or calomel, or kept covered with dry lint powdered with 
either of these. 

It may be said that in all the early and generalized 
syphilides local treatment needs practically to be applied 
only to lesions on exposed parts — that is, face, neck, 
hands, and wrists. The erythematous syphilide is usually 
so ephemeral that no local treatment is necessary. Mer- 
curial baths may, however, be used for general outbreaks 
of syphilis. If the erythematous lesions persist upon the 
exposed parts, their departure can be hastened by the use 
of the ointment of the ammoniate of mercury rubbed in 
morning and night. The same ointment may be applied 
to the papular syphilide. A still more prompt effect can 
1 Med. Rec, 1881, xl., 1. 



SYPHILIS. 563 

be produced, if the patient can be seen often enough, by 
the physician touching each lesion with a solution of the 
bichloride of mercury in alcohol three to five grains to the 
ounce, according to the size of the lesions and the profuse- 
ness of the eruption. Of course, if the eruption is very 
profuse, this plan cannot be followed. It is most applic- 
able to a sparse and relapsing eruption. The mucous 
patch should be touched with the nitrate of silver stick or 
with an aqueous solution of chromic acid, ten grains to 
the ounce. Condylomata are best treated with dusting 
powders, preferably calomel, freely applied and covered 
with absorbent cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber 
next the skin for several days, and then use the ointment. 
If the parts are covered with a very much thickened epi- 
dermis, we may have to remove this by using salicylic acid, 
as in chronic squamous eczema. Mercurial plaster worn 
continuously is efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows unmis- 
takable evidences of containing pus. 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform 
or aristol. If they become sluggish, they may require 
stimulation just as a simple ulcer does. To this end we 
may touch them with balsam of Peru, or add the same to 
our mercurial ointment. Some ulcers will do best under 
the treatment applicable to a simple ulcer, while the iodide 
of potassium is pushed. 

Treatment of Congenital Infantile Syphilis. 
The most popular method is to spread upon pieces of 
flannel a mass of mercurial ointment of about the size of 
the end of the finger, and tie a piece of this one day over 



Ji Calomel, pur., 
Ferri lactatis, 
Sacch. alb., 


gr. iss ; 
gr- i'.j ; 
gr. xlv ; 


3 


1 
2 


Ft. in pulv. No. x. 

Sig. 1-4 powders daily. 









564 DISEASES OF THE SKIN. 

each elbow-joint; another (layover each groin; another, 
under each knee ; and another, over the abdomen, allowing 
the movements of* the child to work the ointment into the 
skin. Or hydrarg. cum creta, one grain three times a 
day, may be given by the mouth. Monti 1 recommends 
the following : 



M. 



The greatest attention must be given to the hygiene of 
the child and to its diet. Cod-liver oil should be given 
along with the mercurial. The nose must be kept clear, 
and if this is not practicable the child must be fed with a 
spoon. After the disappearance of symptoms tonics should 
be given, one of the best being the syrup of the iodide of 
iron. In all other respects the treatment of infantile 
syphilis is the same as that of the acquired form. Kaposi 
commends the tannate of mercury for children ; dose, one- 
half to three-quarters of a grain three times a day. 

Prognosis. The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many eases go no further than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In de- 
bilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 
course, no one being able to promise confidently, no matter 
with what treatment, that relapses and late visceral syphilis 
will not occur. Therefore, the prognosis should be guarded, 
while it is remembered that rare cases of secondary infec- 
tion attest the possibility of complete recovery. 

The prognosis of congenital syphilis is not as good as 
is that of the disease as it affects adults. Many, perhaps 
most, of the cases seen in public institutions die. In pri- 
vate practice more can be done, and we should always count 
upon the remarkable reparative powers of childhood in 
1 Arch. f. Kitiderheilkunde, 1885, vi., 1. 



TATTOO. 565 

making our prognosis. A great deal will depend upon the 
inborn vigor of the child. 

Syringomyelia, or Morvan's Disease, is a disease of the 
spinal cord, the consideration of which belongs rather to 
the neurologist than the dermatologist. It interests us 
because various cutaneous lesions occur during its course, 
such as glossy skin, hyperkeratosis, hyperidrosis, and paro- 
nychia with necrosis of the phalanges ; and because in some 
phases it resembles certain stages of leprosy. 

Syringo-cystadenoma. See Epithelioma, multiple, be- 
nign, cystic. 

Tache Atrophique. See Atrophoderma. 

Tache Bleue. See Pediculosis. 

Tache Caf^-au-lait, seu Congenitale, seu de Feu, sen 
hemorrhagique, seu Pigmentaire, seu Vasculaire, seu Vineuse. 
See JNTsevus. 

Tache Hepatique. See Chloasma. 

Tache Ombrees. See Pediculosis. 

Tan. See Lentigo. 

Tanne. See Acne. 

Tattoo. These well-known stainings of the skin by 
means of India-ink, vermilion, charcoal, and gunpowder, 
although at first objects of pride to the boy or girl, later 
are apt to become objects of aversion. They are very 

Fig. 74. 



•^4 OF REAL SIZE. 

Keyes's punch. 

difficult to remove, especially if they are at all extensive. 
Patient perseverance in going over and over the small 
ones, that cannot be excised, with the electrolytic needle 
will sometimes greatly lessen them, though, of course, we 
thereby substitute a white cicatricial spot for a colored one. 
The needle should be introduced perpendicularly to the 



566 DISEASES OF THE SKIN. 

skin and deeply, and numerous punctures arranged in rows 
thus made. Tin's, of course, is a very slow procedure. 
Powder-grains may be removed by Keyes's punch, by 
making a half-turn over them, and then snipping off the 
small piece with the scissors. (Fig. 74.) 

Ohmann-Dumesnil 1 recommends thrusting into the stain 
a bunch of six to ten very fine cambric needles, tied tightly 
together with silk thread, after dipping them into the 
glycerole of papoid. This is composed of: 



K 



Papoid, 


gr- ij 5 




Aqua? destil., 


3j; 


4 


Glycerin, pur., 


3»j ; 


12 


Ac. hydrochlor. dil., 


g". iij ; 


gtt. iij 



75 



M. 



If required, anaesthesia may be obtained by the ethyl chlo- 
ride spray. The needles are to go deep enough to bring a 
few drops of blood to the surface. After puncturing, pour 
over the surface some of the solution and cover with anti- 
septic gauze. Remove this after two or three days. In 
this way the whole tattoo-mark is to be gone over. It 
may have to be gone over a second time. 

J. Brault 2 recommends tattooing the marks with a solu- 
tion of thirty parts of chloride of zinc and forty parts of 
sterilized water. The superficial eschar falls in five to ten 
days. The process may have to be repeated several times. 

Teigne Faveuse. See Favus. 

Teigne Granulee. See Pediculosis. 

Teigne Imbriqu^e. See Trichophytosis corporis. 

Teigne Pelade. See Alopecia areata. 

Teigne Tondante seu Tonsurante. See Trichophytosis 
capitis. 

Telangiectasis. This is an acquired dilatation of the 
bloodvessels. The condition is well seen in rosacea. But 
it seems to me best to reserve the term for those cutaneous 
lesions in which acquired dilatation of the blood vessels of 
the skin is the only condition present. 

1 New York Med. Jonrn., 1893, lvii., 544. 

2 Ann. de derm, et de syph., 1895, vi., 33. 



TINEA KER10N. 567 

Symptoms. The most common form of the disease is 
ncevus araneus, or what is vulgarly called "spider cancer". 
It occurs in nearly all cases upon the cheeks, near the 
eyelids or bridge of the nose, but may occur anywhere. 
It is usually a single lesion, and consists in a small, central, 
bright-red, slightly raised dot from which radiate fine red 
lines. They sometimes become quite large, though usually 
not more than a half-inch in diameter. This form is seen 
in women and children. It occasionally follows some 
slight injury, but very often seems to come spontaneously. 

Telangiectases in the form of simple dilated blood ves- 
sels of varying size and shape are often seen. Under the 
same heading Crocker places those slightly convex or flat, 
hemp-seed-sized, raised, bright-crimson or purplish spots 
met with in old people. Their favorite site is the upper 
part of the trunk, neck, and face. 

Etiology. Telangiectases sometimes are the result of 
some slight injury, as the prick of a pin or a mosquito-bite. 
Sometimes they are due to continued congestion of the skin 
from disease of the internal organs. In other cases they 
result from a chronic inflammatory disease of the skin. 
They are very common upon the trunk in advanced life. 

Treatment. The treatment of telangiectasis is simple. 
It is only necessary to introduce the electrolytic needle 
into the red central spot, and turn on a current of about 
two milliamperes. The mode of operating is similar to 
that used in destroying superfluous hair, and is described 
in the section on Hypertrichosis. It may be destroyed 
by touching it with a drop of nitric acid, or puncturing it 
with a white-hot needle. 

Tetter. See Eczema. 

Tinea Amiantacea, seu Asbestina, seu Furfuracea. See 
Seborrhoea. 

Tinea Circinata, seu Cruris, seu Imbricata. See Tricho- 
phytosis corporis. 

Tinea Decalvans. See Alopecia areata. 

Tinea Favosa. See Favus. 

Tinea Kerion. See Trichophytosis capitis. 



568 DISEASES OF THE SKIN. 

Tinea Nodosa. This disease is also named trichomycosis 
palmellina and nodositas pilorum microphytica. This is 
a condition of* incrustation of the hairs with a fungous 
growth forming dry, hard, elongated, formless masses 
varying in color from olive to brownish yellow, giving a 
rough feel to the hair. The hair follicles are unaffected, 
and the hair is firmly seated in them. The hair may be 
simply incrusted or it may be split. The free end of the 
hair is more affected than the proximal end. The spores 
composing the incrustations are similar to the trichophy- 
ton, but larger. It is often seen on the axillary hairs. 
It differs from piedra in not affecting the scalp hair and in 
its fungus. 

Tinea Sycosis. See Trichophytosis barbae. 

Tinea Tondens sen Tonsurans. See Trichophytosis 

capitis. 

Tinea Trichophytina. See Trichophytosis. 
Tinea Versicolor. See Chromophytosis. 
Trichauxis. See Hypertrichosis. 

Trichiasis. This is a congenital or acquired displace- 
ment of the oilise so that they point backward and scratch 
the cornea. Both lids of both eyes are usually affected. 

The best tueatment is the destruction of the hair by 
means of the electrolytic needle, as described in the section 
upon Hypertrichosis. 

Trichoclasia. See Trichorrhexis nodosa. 

Trichoptylose. See Trichorrhexis nodosa. 

Trichomycose Noueuse. See Piedra. 

Trichomycosis Nodosa. See Leptothrix. 

Trichomycosis Palmellina. See Tinea nodosa. 

Trichinosis Cana vel Discolor. See Canities. 

Trichonosis Furfuracea. See Trichophytosis capitis. 

Trichophytie Circinee. See Trichophytosis corporis. 

Trichophytie Sycosique. See Trichophytosis barbae. 



TBICHOPH YTGSIS. 569 

Trichophytosis. A contagious disease of the skin and 
hair, occurring most often in children, due to the invasion 
of the epidermis by the trichophyton fungus, and charac- 
terized by the formation of circular or annular scaly 
patches, and partial loss of hair. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgement and grow 
on the general cutaneous surface, in the scalp, beard, or 
nails — that is, in the epidermic structures. In these dif- 
ferent localities it develops so differently as to produce 
very different clinical pictures. I shall describe each one 
by itself and give its differential diagnosis, treating all 
matters of etiology and treatment collectively. 

Trichophytosis Corporis. Synonyms : Tinea circinata ; 
Herpes circinatus; (Fr.) Herpes circine, Trichophytie cir- 
cinee ; (Ger.) Scheerende Flechte ; Ringworm of the body. 

Symptoms. This is the simplest and most readily cured 
of all the forms of ringworm. It begins as a small, pale- 
red, slightly raised spot, which, growing, spreads out into 
a round, sharply defined, scaly patch ; then it clears up in 
the middle, becomes ring shaped, and advances with a 
raised border that may be vesicular ; or crusted from the. 
drying of the vesicular contents ; or papular and scaly. 
After a time it either ceases to spread, or, enlarging, the 
edge of the ring becomes broken in places. At last it 
undergoes spontaneous involution. There may be but a 
single patch or there may be a number of patches. If 
two circles meet at their peripheries, they coalesce and 
form gyrate figures. Very often rings do not form, and 
we have only a round, sharply defined, scaly, circular 
patch. The exposed parts — face, hands, and neck — are 
the most common sites for the eruption. In rare cases 
ringworm may be widely disseminated over the body. A 
slight amount of itching is the only subjective symptom, 
and that may be wanting. 

Another form of ringworm of the body is that known 
as eczema marginatum, which is ringworm located in the 
crotch or axilla. It is usually of a more highly inflam- 
matory character than the same disease on other parts of 



570 



DISEASES OF THE SKIN. 



the body, and resembles an eczema very closely — in fact, 
it is often complicated by an eczema. The edge of the 
patch is sharply defined, raised, scalloped, papular, and 
scaly, while the center may be smooth or pigmented and 
crusted. The patch often attains large dimensions, run- 
ning down the inside of the thigh, up over the abdomen, 

Fig. 75. 




Trichophytosis corporis. 
(From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 



and backward over the perineum. Usually the inside of 
both thighs is affected. There is considerable itching. 
The same symptoms are presented when the axillae are 
affected. There is also a true eczema of the crotch that 
is not due to the trichophyton, but resembles the form 
just described. 

Tinea imbrieata is supposed to be a very aggravated 
form of body ringworm occurring in tropical countries. 
But Manson l says that it differs from ordinary ringworm 
1 Brit. Journ. Dernmt., 1892, iv., 5. 



TRICHOPH YTOSIS. 5 7 1 

in affecting a very large part of the body at the same 
time ; in avoiding hairy parts and sparing the hair ; in 
an absence of signs of inflammation ; in not forming a 
single ring, but ring within ring, and recurring in parts 
gone over ; in having .large, abundant scales ; in profuse 
fungous growth ; in always breeding true in inoculation- 
experiments ; and in occurring only in certain parts of 
the world. 

Diagnosis. Trichophytosis corporis is readily diag- 
nosed, as its appearance is distinctive. Favus of the body 
may spread out into a circular patch, but soon it will show 
the distinctive sulphur-yellow cupped crusts. Psoriasis 
on the body will have a brighter red color ; its scales will 
be more abundant, thicker, and brighter ; it will be found 
on the tips of the elbows and over the knees, and will be 
more profuse and disseminated ; and examination of the 
scales will show an absence of fungus. The scaling pap- 
ular syphilide or the squamous syphilide will not itch ; 
there will be no fungus in the scales ; the color will be that 
of raw ham ; the base will be more infiltrated ; it will run 
a more chronic course ; and will not yield so readily to 
treatment. Seborrhoea of the chest may occur in rings, 
but its location will suggest its origin ; the skin is greasy, 
the scales rub off easily, and there is no fungus in 
them. Eczema of the crotch or axilla differs from ring- 
worm of the same region in not having a so sharply 
defined and scalloped or festooned border ; in forming a 
more evenly diseased patch with no sound skin in it ; and 
in having no fungus in the scales taken from it. Pity- 
riasis rosea is more widely distributed than is ringworm, 
and spreads more rapidly : it is not so scaly ; has a more 
yellowish center ; is usually most abundant on the trunk ; 
shows no fungus under the microscope ; and the eruption 
is made up of both macules and rings. 

Trichophytosis Capitis. Synonyms : l Herpes tonsurans 
seu circinatus, seu squamosus ; Tinea tonsurans, seu ton- 
dens ; Porrigo furfurans ; Dermatomyiasis tonsurans 

1 I can mention here only the more common ones, as their number is 
legion. - : 



572 DISEASES OF THE SKIN. 

(Kobner); (Fr.) Herpes tonsurante, Teigue tondante ou 
tonsurante, L'herpes circine parasitaire ; (Ger.) Scheerende 
Fleehte; (Slav.) Ringskurv ; Ringworm of the scalp. 

Symptoms. This form of ringworm is seen almost 
exclusively in infants and children. As puberty or early 
adult life is reached the disease, no matter how long con- 



Fig. 7 




Trichophytosis capitis. 1 (Fox.) 



tinued, and how severe it may be, tends to get well of 
itself. It begins as a single vesicle or a small, insignifi- 
cant, red, scaly spot that would pass without suspicion of 
its nature unless other cases of ringworm put us on our 
guard. From this small beginning the disease spreads 
peripherally to form a circular patch, which is red, cov- 
1 G. H. Fox : Skin Diseases of Children. Wood, N. Y., 1897. 



TRICHOPHYTOSIS. 573 

ered with grayish scales, sharply defined, perhaps slightly 
elevated, and partially bald. Inspection of the patch will 
show a number of broken-off stumps of hair with split 
ends. These stumps arc characteristic of the disease. 
The hair growing in and about the patch is dry, lusterless, 
split, and brittle. Attempts at epilation break it off, and 
if it is indented with the finger-nail it will take a sharp 
angle and retain it. This shows that it has lost its resil- 
iency. Apparently healthy hairs are sometimes growing 
from the patch. The size of the patch varies greatly. It 
may be no larger than that of a ten-cent piece, or it may 
be so large as to denude a good part of the scalp. These 
large patches are usually formed by the coalescence of 
several small ones, and then they lose their circular out- 
line and become scalloped. There may be but a single 
patch, or there maybe a number of them. After attaining 
the size of a half-inch to one inch in diameter the patches 
may remain stationary in size or increase slowly. The 
most frequent sites are the vertex and parietal regions. 
Pruritus of greater or less degree is usually complained of, 
and it may be the first symptom that draws attention to 
the child's scalp. The course of the disease is exceedingly 
chronic. It does not produce permanent baldness. 

This is the typical " ringworm," as seen in the vast 
majority of cases. Sometimes, instead of being scarcely 
or not at all raised above the surface of the skin, the 
patch, usually a single one, begins to swell up, becomes 
raised, uneven, and boggy, and we have the condition 
described as hcrion (which see). Another variety is what 
Liveing terms bald tinea tonsurans. This begins as an 
ordinary ringworm, but after a time the hair all falls out, 
the scalp is smooth and without scales, as in alopecia 
ai-eata, and at its border there may be found short broken 
hairs, like those seen in the latter disease. At first this 
change takes place in one patch alone, and we will be 
guided to a right diagnosis of the disease by the appear- 
ances of the other patches. Later, these too become 
altered, and then it would be hard to make the diagnosis 
without the history of there having been scaly patches. 
This is an infrequent form of the disease. 



574 DISEASES OF THE SKIN. 

Still another form is called disseminated ringworm. Here 
the patchy, areated character of the disease has disappeared, 
the hair has apparently grown in nicely, and there is seem- 
ingly only a scurvy condition of the scalp. This is a dan- 
gerous form, because the child is often regarded as well and 
yet is quite capable of spreading infection. Careful exami- 
nation of the case, by causing the child to stand with his 
back to the physician, and turning the hair slowly back- 
ward against its direction of growth, will show here and 
there " stumps," and also the presence of hairs that stand 
up from the head for a few moments. Normal hair falls 
quickly back into place, which is not the case with hair 
affected with ringworm. 

A pustular form is sometimes described. It is simply 
a ringworm occurring in a strumous subject, in whom all 
inflammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. Trichophytosis capitis must be differenti- 
ated from alopecia areata, favus, eczema, seborrhcea, and 
psoriasis. From alopecia areata it differs in being scaly; 
in not producing perfectly bald patches; in its much slower 
progress ; in the presence of " stumps ;" and in having the 
tricophyton fungus in the hair, as seen under the micro- 
scope. From favus it differs in the absence of the sulphur- 
yellow cupped crusts of that disease ; in not having such 
heaped-up asbestos-like crusts ; in forming distinct round 
patches ; in the more brittle character of its hair ; in not 
producing red, smooth, permanently bald spots that later 
become white and cicatricial, and in showing a marked 
tendency to get well of itself as puberty is reached. The 
diagnosis between them by the microscope is not easy 
without a knowledge of the appearances on the skin. The 
spores of favus are more polymorphous and somewhat 
larger than those of trichophytosis, and its mycelia are 
more abundant than its spores. From eczema it differs 
in the more circumscribed and circular character of its 
patches ; in being less itchy ; and in the presence of broken- 
off hairs and stumps. The presence of these broken-off 
hairs and stumps, and of the fungus in the hair and scales, 



TRICHOPHYTOSIS. 



575 



will sufficiently distinguish ringworm from both seborrhoea 
and psoriasis. 

Trichophytosis Barbae. Synonyms : Tinea sycosis, seu 
barbae ; Sycosis parasitaria seu parasitica ; Herpes ton- 
surans barbae; (Fr.) Trichophytie sycosique, Sycosis 
parasitaire ; (Ger.) Parasitische Bartfinne ; (It.) Sicosi 
parasitaria ; (Eng.) Barber's itch, Ringworm of the beard. 

When the trichophyton invades the beard, at first it 
forms simply a superficial scaly circular patch which 

Fig. 77. 




Trichophytosis barbae. 
(From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 



increases in size, just as on the scalp, producing broken-off 
hairs and a partially bald area. There are usually several 
of these areas upon the chin and cheeks. If not checked 
by treatment, we have the more characteristic develop- 



576 DISEASES OF THE SKIN. 

ment of the disease, in which there will be either some 
pustules pierced by hairs, or else a group of large 
nodular swellings, varying in size from that of a split pea 
to that of a half-cherry, arranged in the form of a circle. 
There are usually several groups of them. The nodules 
are prominently raised and usually rounded. (Fig. 77.) 
They are of a congested red or purple color. They may 
be hard and scaly ; or give exit to a sticky discharge ; or, 
rarely, suppurate. The hair over them is broken, or 
more or less wanting. Usually itching and burning are 
complained of. 

Diagnosis. The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. 
From sycosis it differs in affecting the lower part of the 
face and sparing the upper lip ; in presenting broken-off 
hair ; in having grouped nodules ; and in the presence of 
the fungus in the hair. Sycosis is more acute in its mani- 
festations, and is characterized by its many discrete pus- 
tules pierced by hair. From eczema it differs in the same 
points as it does from sycosis, and also in being less crusted, 
and in the ease with which the hair can be plucked or will 
break. Eczema is also a disease of the skin and not of the 
hair. The tubercular syphilide bears a resemblance to tricho- 
phytosis barbae at times. It differs from it in forming but 
a single group, in being of a darker color, and in under- 
going a steady course of development toward final recovery, 
leaving, not infrequently, permanent scars. Other symp- 
toms of syphilis will often be found, and its whole history 
will be different. 

Trichophytosis Unguium, or onychomycosis, is ring- 
worm as it affects the nails. It begins as a change in 
color <>f the nail-substance and with a loss of its trans- 
parency. The nail becomes uneven and thickened, and 
its edge, which is usually the part first attacked, becomes 
raised from its bed by an accumulation of scaly matter 
under it. A progressive atrophy takes place, and at last 
the nail breaks and falls either in part or as a whole. 
There may be but one nail affected, or all the nails, both 
of the hands and feet, may be attacked, then usually con- 



TRICHOPHYTOSIS. 577 

secutively. Many obscure cases of atrophy of the nail 
will be found to be due to ringworm when the scrapings 
from them are examined under the microscope. 

Diagnosis. The appearances presented by the nails 
are so similar to those seen in psoriasis and other diseases 
in which the nails become atrophied, that a positive diag- 
nosis can be made by the microscope alone, unless there 
should be symptoms of the one or the other disease 
present elsewhere on the body as a guide. 

Having now described the different varieties of ring- 
worm with their differential diagnosis, we pass on to 
study the factors common to all. 

Etiology. The cause of the disease is contagion with 
the trichophyton fungus. This contagion may be direct, 
from person to person, or indirect by means of brushes, 
towels, clothing, and the like. It is possible that the air 
may become so full of the fungus in epidemics in crowded 
children's asylums that contagion may be by means of the 
fungus lighting upon the head or body. The disease is 
very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and 
horses, constituting in them one form of mange, they are 
a very frequent source of contagion. Ringworm of the 
scalp is often communicated by means of brushes and 
headgear. Ringworm of the beard is conveyed by means 
of brushes, towels, and the barber's fingers. Ringworm 
of the nail comes from scratching. Some skins seem to 
furnish a better soil for the growth of the fungus than do 
others. Children have ringworm of the scalp ; adults 
almost never. There is no peculiarity of constitution that 
predisposes to the disease. It attacks all classes and is 
seen in all conditions of society, though, of course, it is 
most common among the crowded poor. 

Pathology. The fungus of ringworm, has its habitat 
in the epidermic structures of the skin. On the general 
cutaneous surface it is so superficially located as to be 
readily destroyed. When it attacks the hair and nails it 
penetrates below the skin in their epidermic structures, 
and is much more difficult of cure. 



578 DISEASES OF THE SKIN. 

The fungus (Fig. 78) consists in mycelia and conidia 
(spores), the proportion of which to each other varies ; in 
the hair of the scalp and beard the number of spores far 
exceeds that of the mycelia. Sometimes they are so nu- 
merous as to be crowded together in lines. On the gen- 
eral surface the mycelia are far more numerous. They 
are long, slender, branched, straight or crooked bodies. 
The spores are round, small, and refract light. Having 
become lodged in the skin, the fungus always sets up a 
certain amount of irritation by its processes of growth. If 

Fig. 78. 

• , - I • > - '4 



!, 









Trichophyton tonsurans in hair shaft and follicle. (After Kaposi.) 

it lands upon hairy regions, it attacks the hair secondarily, 
passing down the walls of the hair follicle to a greater or 
less depth before it penetrates the cuticle of the hair and 
gains access to its substance. Having gained access, it 
vegetates freely, and may often be traced throughout the 
whole length of the hair. Robinson and others have 
found the fungus in the peri-follicular tissue. Its pres- 
ence always causes more or less peri-folliculitis. If the 



TRICHOPHYTOSIS. 579 

peri-folliculitis is very great, permanent baldness may 
result. In trichophytosis unguium the fungus grows in 
the substance of the nails. 

Sabouraud l and others have demonstrated that there are 
several fungi producing ringworm, the most common being 
the microsporon audouini, and the trichophyton endothrix 
and ectothrix. C. J. White, 2 repeating Sabouraud's inves- 
tigations in this country, says that fifty-two per cent, of 
ringworm in this country is due to the microsporon, 
most all being on children's scalps. In the hairs the spores 
are small, round, glistening, and placed closely together. 
They are more equal in size than are those of the other 
forms of ringworm. The microsporon does not grow well on 
the skin. The other forms of ringworm fungi rarely affect 
the scalp. The trichophyton endothrix in the hair runs 
in lines parallel to the long axis of the hair. Its spores are 
quadrangular, with rounded corners, and vary considerably 
in size. It causes most cases of ringworm of non-hairy 
parts, and some cases of ringworm of the scalp, especially 
those that have an eczematous appearance. The ectothrix 
variety most often affects the bearded portion of the face, 
and causes the deep or suppurating forms of ringworm. 
It also produces kerion of the scalp. The spores resemble 
the preceding, but grow around the hairs rather than in 
them. It is a pyogenic fungus. 

Treatment. There is no disease of the skin much 
more easy of cure than trichophytosis of the general sur- 
face of the skin, and none much more difficult of cure 
than trichophytosis capitis. 

Trichophytosis corporis may be readily cured with al- 
most any slightly irritating and astringent application, 
and by all the antiparasitics. It may be cured by 
means of common ink, or by using vinegar in which a 
copper coin has been soaked. The scales should be 
removed with soap and water, and an ointment of 
sulphur, or ammoniate of mercury, or chrysarobin, or 
pyrogallol, be applied ; or simply paint the patch with 
tincture of iodine, acetic or sulphurous acid, or a solution 

1 Diag. et Trait, de la Pelade et des Teignes de i'Enfant. Paris, 1895. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1899, xvii., No. 1. 



580 DISEASES OF THE SKIN. 

of bichloride of mercury, three to five grains to the ounce. 
The last is a good method for adults, as it does not stain 
the skin, and one application will usually cure the disease. 
It is rather too strong for children. Other applications 
are a saturated solution of hyposulphite of soda ; oleate of 
copper, half a drachm to the ounce of ointment ; and 
salicylic acid, five or ten per cent, strength, which by no 
means exhausts the list. 

Trichophytosis cruris et axilla', or eczema marginatum, is 
not so easy to cure as the preceding variety, but it can be 
cured by any of the means datailed above. In using 
chrysarobin, here as elsewhere, we should bear in mind its 
irritant qualities. Taylor has recommended painting the 
parts with two to four grains of bichloride of mercuy in one 
ounce of tincture of benzoin. Hardaway speaks well of 
modified Wilkinson's ointment. Some cases will make a 
good recovery under an ointment containing oil of cade, one 
drachm to the ounce. This is specially good after the use 
of sulphur or other antiparasitic to kill the fungus, as it 
is curative of the eczema that often remains. 

Trichophytosis capitis is the most obstinate form of ring- 
worm to cure. The fungus is present abundantly deep 
down in the skin, and each hair is a separate focus of dis- 
ease. The difficulty we have to contend against is to 
cause our remedies to enter the skin deeply enough to de- 
stroy the fungus. Nature gives us a hint as to the cure 
of the disease when a kerion forms that is not infrequently 
followed by disappearance of the disease. Most of the 
so-called remedies for ringworm are irritants to the skin, 
and do good quite as much by the irritation they cause as 
by their parasiticide properties. 

If we see the case at its earliest stage, we may sometimes 
succeed in aborting the disease by the application of the 
bichloride of mercury, five or ten grains to the ounce. 
Usually when the case is brought to us it has gone too far 
for aborting it. Then we may sometimes cure the case 
promptly, but most often it is an affair of months and, 
perhaps, years. The first requisite for a cure is faith on 
the part of the patient, so that the second element, persist- 
ency, can come into play ; and then by the persevering 



TRICHOPHYTOSIS. 581 

use of parasiticides a cure may be effected. As each case 
is a source of contagion, steps must be taken to isolate the 
case if it occur in an asylum or school. If it occur outside 
of an institution, the parents must be cautioned not to 
allow the child's hat or clothing to be worn by any other 
child, and the child must be taken out of school. To 
assure still further the safety of others, an antiparasitic 
must be applied to the child's head, such as a one or two 
per cent, solution of salicylic acid in alcohol and castor oil. 
The child should also wear a linen cap over the whole 
head. These regulations are difficult to carry out in private 
practice. 

The ringworm patch or patches should be scrubbed with 
soap and water so as to remove all the scales before we 
make any local application. Tar soap is a good one to use 
for the purpose. Then the hair should either be cut short, 
pulled from or shaved off the patches, and for about a 
quarter of an inch about them. Now the case is ready for 
the chosen parasiticide. Whatever is used in the form of 
an ointment or oil, it should not be smeared over the sur- 
face, but worked in, as it were. The remedies we use are 
exhibited in the form of ointments, oils, varnishes, pastes, 
solutions, and plasters. It is, unfortunately, necessary to 
give a lengthy list of remedies from 'which the reader may 
select. One of the oldest and most used of them is the 
officinal sulphur ointment, full strength or diluted according 
to reaction. Here, as elsewhere, when an ointment is men- 
tioned, it is to be understood that it may be made with lard, 
vaseline, lanolin softened with oil, plasment (mucilage of 
Irish moss), or gelanthum. The last is to be preferred be- 
cause it is not greasy, sinks readily into the skin, and leaves 
a slight film over the patches that prevents, to a certain ex- 
tent, the escape of the spores into the air. The persistent 
daily use of sulphur ointment, combined with epilation, 
and scrubbing of the patch with soap and water about once 
a week, will cure the disease. Sulphur may also be used 
in combination with other drugs. One of the most efficient 
remedies is 

R 01. tiglii, 3j; 41 

Ungt. sulphuris, |j ; 30l M. 



582 DISEASES OF THE SKIN. 

This is to be rubbed into the patch once a day until symp- 
toms of reaction appear, the patch becoming swollen and 
red. When this subsides the patch will be smooth like as 
in alopecia areata. There is always danger of producing 
permanent baldness, but thus far in all my cases the hair 
has come in all right. As nothing has yet been found to 
render sulphur soluble in any amount, it must always be 
exhibited in ointment- or paste-form. 

Mercury is another old stand-by. It may be used as a 
solution of the bichloride in alcohol (grs. j— iij ad sj), whose 
application should not be intrusted to any one but a physi- 
cian or trained nurse. It is to be used two or three times 
a day, its effect carefully watched, and, of course, it should 
not be applied to large surfaces. It may be employed as 
recommended by Kerley, 1 who reports having cured a 
number of cases in from two to twenty weeks by using a 
solution made by adding two grains of the bichloride dis- 
solved in sufficient alcohol to a half ounce each of kerosene 
and olive oil, daily rubbed into patches as well as applied 
all over the scalp. When inflammation is caused, the 
application is stopped, and a simple ointment is used until 
the irritation subsides. Then the bichloride is again ap- 
plied. The scalp is to be washed often. He thinks that 
a cure will be hastened by using a saturated solution of 
iodine on alternate days with a bichloride solution. Crocker 
thinks highly of the bichloride, three grains dissolved in 
alcohol, to the ounce of turpentine. Tincture of benzoin 
is a good excipient for the bichloride, according to Levi- 
seur, 2 who recommends the application of it, one to two 
parts to three hundred parts of benzoin, once a week, 
with the daily use of salicylic acid ointment in ten to 
twenty per cent, strength. All the mercurial ointments 
are useful, but are not so prompt in their action as other 
remedies. 

The remedies recommended in the treatment of ringworm 
of the body are all of use in the same disease of the scalp, 
and need not be repeated here. The main modification is the 
epilation that should precede their application. Instead of 

1 New York Med. Journ., 1891, liv., 396. 

2 Med. Kec., 1889, xxxv., 594. 



TRICHOPHYTOSIS. 583 

using tincture of iodine, the English authors commend Cos- 
ter's paint, made of two drachms of iodine and six drachms 
of the light oil of wood-tar, which is to be firmly applied 
with a stiff brush. A black crust will form after two or three 
days, which should be removed with the forceps. The part 
should then be washed with soap and water, and the paint 
again applied. Two or three applications of it may be made 
to an infant's scalp, or it may be continued longer in chil- 
dren over four years of age. The best way of using iodine, 
and in my experience the best treatment for ringworm, is to 
rub up one drachm of the crystals of iodine in one ounce 
of goose-grease. This is to be well rubbed into the patches 
with a stencil- or stiff paint-brush. It causes but little 
reaction and cures speedily. The iodine is found staining 
the hairs deeply when the hairs are examined under the 
microscope. 

Chrysarobin in ten per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis being 
ever borne in mind. Pyrogallol in five to fifteen per cent, 
in the same excipients, with or without the addition of half 
a drachm of salicylic acid to the ounce, is a reliable prepa- 
ration, ft-naphtol and hydronaphtol are commendable. 
One of the neatest methods for treating ringworm is that 
commended by Dockrell, 1 and it has proved useful in my 
hands. He directs that after shaving and washing the 
head with a five per cent, hydronaphtol soap and hot water, 
the part is to be dried and covered with strips of ten per 
cent, hydronaphtol plaster so that they overlap at the edge. 
Over all is to be poured some melted ten per cent, hydro- 
naphtol jelly. At the end of four days the plaster is to 
be removed, the head again washed, and a twenty per cent, 
plaster applied and worn for one week. Finally a ten per 
cent, plaster is to be worn for ten days. If not well then, 
the process may be repeated. Naphtol may be used as a 
one per cent, solution in alcohol, or in the form of a paste, 
as recommended by Kaposi : 2 

1 Lancet, 1889, ii., 1110. 

2 Wien. med. Wochenschr., 1881, xxxi., 617. 



584 DISEASES OF THE SKIN. 



R 0-Naphtol., 

Spt. sap. viridis, 
Alcohol., 
Bals. peruv., 
Sulph. loti, 



gr. xv; 


li 


gr. xxx ; 

3J 3^ ; 


2 


50 


gr. xxx ; 


2 


3'J ss ; 


10 1 



Either may be applied twice a day for two or three days, 
and then followed by a thorough scrubbing with green 
soap. Thymol in five to ten per cent, strength, dissolved 
in chloroform and olive oil, is recommended by Malcolm 
Morris. Formalin is commended by some, but condemned 
by others, on account of the severe irritation it is capable 
of setting up. 

Harrison l endeavored to effect entrance of his remedies 
to the deeper parts of the skin by first applying to the 
scalp solution No. 1, composed of half a drachm of po- 
tassium iodide in one ounce of liquor potassse. After a 
few days he applied solution No. 2, composed of three 
grains of corrosive sublimate to one ounce of sweet spirits 
of nitre or of water. This treatment requires careful 
watching. Foulis 2 recommends rubbing turpentine into 
the scalp, after cutting the hair, until it smarts. Then the 
scalp is to be scrubbed with ten per cent, carbolic soap, 
dried, and painted with two or three coats of tincture of 
iodine. When dry the whole head is to be anointed with 
carbolized oil, 1 : 20. This procedure is to be carried out 
once a day. Alder Smith has found useful a saturated 
solution of boric acid, as follows : 

R Ac. boric, giv; 15| 

.Etheris, %v ; 150 

Alcoholis, ad gxx ; ad GOO] M. 

It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

H. B. Sheffield 3 recommends clipping the hair close, and 
applying over the whole scalp once a day for five days 



R Ac. carbolici, "^ 
01. petrolati 



aa ^ss ; aa 65| 

Tinct. iodini, ) -- -.. -- ,.,J 

Ol.ricini, } aa &>; aall ° 

01. rusci, ad 5iv ; ad 500 M. 

1 Brit. Med. Journ., 1885, ii., 134. ! Ibid., 18S5, i., 536. 

a New York Med. Journ., 189S, Ixvii., 680. 



TRICHOPHYTOSIS. 585 

This is to be wiped off with a cloth on the sixth day, the 
hair clipped, and the scalp thoroughly washed with green 
soap. On the seventh day the treatment is to be repeated, 
and so on for three or four weeks, or until no more fungus 
is found and new hair appears. A ten per cent, sulphur 
ointment is then to be used for a few days, and for two 
weeks afterward 

R Resorcin., "\ -- _. -- ■,„ 

Ac salicylic!,/ aa 3 ; 



Alcoholis, §j ; 120 

01. ricini, ad giv ; ad 500 



M. 



In very chronic cases and in the disseminated form it 
may be necessary to blister the patch by means of croton 
oil or acetic acid. Croton oil must always be used with 
caution and to small areas, as it is capable of producing 
permanent baldness. One part in ten of olive oil is usually 
sufficient, but the strength may be increased till we have 
it sufficiently strong to cause a mild degree of pustulation, 
when the hairs may be easily plucked. In disseminated 
ringworm a drop of the pure oil may be applied to each 
diseased follicle, and as soon as a pustule forms the hair 
should be pulled out. In very obstinate cases electrolysis 
may be practised to individual hairs, which, like the croton 
oil, will permanently destroy the hair. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths 
will be rendered more open for the entrance of the appli- 
cations, which should always follow epilation. Besnier 
epilates around the patches, and asserts that then the dis- 
ease rarely spreads to neighboring parts. 

Treatment should be continued until there are no more 
stumps or broken-off hairs to be seen ; till the microscope 
fails to reveal any fungus in the hair after prolonged search, 
and until the scalp is no more scaly. It is well to use the 
following' : 



R Hydrarg. amnion., .►),] ; 3 

Hydrarg. chlor. mitis, J^ij ; 7 

Vaselini, §j ; 30 



75 
50 
M. 



586 DISEASES OF THE SKIN. 

or a sulphur ointment for several months after apparent 
cure. 

Trichophytosis barbae, is treated along the same lines as 
when the scalp is the seat of the disease. The beard 
should not be shaved, but cut short with scissors. Here 
epilation is of more positive value, as the hairs over the 
nodules will come out easily. It is possible to abort the 
disease before it has implicated the hair by the application 
of a solution of five to ten grains of bichloride of mercury 
in alcohol. A ten per cent, solution of resorcin or an 
ointment of the same strength may accomplish the same 
end. After the disease has got fully underway, systematic 
epilation, daily shaving by the patient himself, and the 
thorough application of one of the parasiticide preparations 
mentioned in the preceding section, especially the iodine 
goose-grease, will effect a cure. 

Trichophytosis unguium may be treated by producing a 
paronychia. This maybe done by Pelizzari's ' method 
of keeping green soap upon the nail under a rubber cot 
for a few days, until the nail is softened. Then equal 
parts of olive oil and pyrogallic acid are to be applied till 
the nail loosens, when it is to be removed and the finger 
dressed with iodoform. Thin 2 recommends scraping the 
affected nails very thin, applying liquor potassse to soften 
them, and then dabbing on creosote, or acetic acid, or a 
solution of two to five grains of bichloride of mercury in 
alcohol. Crocker speaks well of using Harrison's plan 
for treating ringworm of the scalp, which see. Solution 
No. 1 should be applied after scraping and kept on for 
fifteen minutes, covered with oiled silk ; then No. 2 
applied in the same way and kept on for twenty-four 
hours. These should be repeated till the cure is effected. 
If the skin should become tender or begin to peel, the 
solutions should be stopped, and one of hyposulphite of 
soda used until the skin heals. A ten per cent, salicylic 
acid plaster worn constantly over the nail is a good plan of 
treatment. 

Prognosis. All forms of ringworm, excepting that of 

1 Giorn. Ital. d. Mai. Yen. edel Pelle, March, 1888. 

2 Practitioner, May, 1887, et seq. 



TUBERCULOSIS CUTIS. 58\ 

the general surface of the body, are very obstinate, but 
persevering and intelligent treatment will cure them all. 
The most obstinate form is that of the scalp, and a speedy 
cure should never be promised. It must always be 
remembered that as puberty is reached it tends to spon- 
taneous cure. 

Trichoptilosis. ] 

Trichorrhexis Nodosa. \ See Atrophia pilorum propria. 

Trichoxerosis. J 

Tubercula Miliaria. ) 

, „ , \ See Milium. 

Tubercula Sebacea. J 

Tubercule Anatomique. See Tuberculosis verrucosa 
cutis. 

Tuberculosis Cutis. Symptoms. This is a rare disease, 
having been met with by Chiari but five times in between 
3000 and 4000 post-mortems of those who had died of 
tuberculosis. It occurs almost exclusively about the 
mucous orifices — mouth, anus, vulva, and glans penis. 
Crocker describes the disease as follows : " The lesions 
consist of one or more discrete, shallow, not painful ulcers, 
which form apparently spontaneously, have an irregular, 
eroded, moderately infiltrated edge, and when the crusts, 
which soon cover them, are removed, show a reddish- 
yellow, granular surface, with a thin, scanty secretion. 
They never heal, but spread slowly and continuously, and 
may coalesce with neighboring ulcers, becoming serpigi- 
nous ; they may thus extend over an area of one or more 
square inches ; but, as a rule, they are small. AVTien on 
mucous membranes, yellow miliary papules exist near 
them." They are due to local infection with the tubercle 
bacillus, and are a part of a general tuberculosis. Their 
diagnosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the 
primary disease. 

Teeatment. Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 



588 DISEASES OF THE SKIN. 

Tuberculosis Verrucosa Cutis. Synonyms : Verruca 
necrogenica ; Lupus verrucosus ; Scrofuloderma verruco- 
sura ; (Fr.) Lupus sclereux, ou 1. papillaire verruqueux ; 
Anatomical tubercle ; Post-mortem warts. 

These names have been given by different writers to 
what may be regarded as simply varying aspects of the 
disease described by Riehl and Paltauf 1 as tuberculosis 
verrucosa cutis. It is one of the rare skin diseases, but 
not so very infrequent as statistics would show. It was 

Fig. 79. 




Tuberculosis verrucosa cutis. (After Hyde.) 

met with four times in 3726 cases in G. H. Fox's service 
at the Yanderbilt Clinic in 1892. 

Symptoms. 2 The disease occurs usually in the form of 
a single round or oval patch. There may be several such 
patches. If two patches join, irregularly shaped patches, 
with scalloped border, may form, and perhaps become 
serpiginous. In size the single patches vary from that of 
a lentil up to that of a silver half-dollar. Around the 
patch is a narrow zone of erythema, of a bright red, that 

1 Vierteljahr. f. Derm. u. Syph., 1886, xiii., 19. 
* The description here given is taken, for the most part, from the 
above-mentioned article bv Iiiehl and Paltauf. 



TUBERCULOSIS CUTIS. 589 

disappears under pressure. Its surface is smooth, and 
often more shiny than the normal skin. Toward the next 
zone it is slightly elevated. Its follicular openings are 
preserved. 

Inside of this zone is a row of small, discrete, super- 
ficial pustules, whose covers are so thin that they break 
easily, and we find only the crusts and scales left by them. 
The color of this zone is brown or livid red, and it can- 
not be pressed out entirely, showing that there is some 
infiltration of the skin. This zone is slightly raised, but 
the one to its inner side is markedly so. It has also an 
irregularly knobby surface, becoming distinctly warty 
toward the center of the growth, the warts being rounded 
or pointed. The nearer the center the warts are the 
larger they are, some of them being five to seven milli- 
meters long. The whole surface of this zone is more or 
less scaly or crusted. The color is brownish red. The 
warty growths are often close together with fissures between 
them, and little erosions and pustules. If the patch is 
pinched up between the fingers, little drops of pus may be 
made to well up from between the papilla?. The mouths 
of the follicles are destroyed. In some cases acute inflam- 
mation may occur, and the patch will swell up and become 
more angry-looking. 

After a time the patch begins to flatten in the middle 
by the disappearance of the warty growths, and at last 
becomes changed into a smooth or slightly scaling cica- 
trix, which is thin and soft, with a delicate sieve- or net- 
like appearance. 

The patch is always freely movable upon the under- 
lying parts, and usually gives rise to no subjective symp- 
toms. Sometimes pain is complained of on pressure. 
The growth is by the addition of new lesions on the pe- 
riphery of the old patch, and is usually very slow, and at 
intervals with pauses between. It is a chronic affection, 
showing no tendency to spontaneous recovery. 

Such are the typical disease and its course. In the 
description of the different diseases named above will be 
found some deviations from the type, but they all agree 
in the main, and are probably all one and the same dis- 



590 DISEASES OF THE SKIX. 

ease. It is met with most often upon the back of the 
hands and fingers, but may occur anywhere. 

Etiology. The cause of this form of tuberculosis is 
the inoculation of the skin with the tubercle bacillus, 
which has been found in sections taken from the patches. 
The disease is seen most frequently in men, and is spe- 
cially prevalent in butchers and those who have to do 
with animals, such as hostlers and drovers. Dead-house 
attendants are also its victims not infrequently. Cases 
have been directly traced to inoculation with tubercular 
tissue. 

DIAGNOSIS. Though allied to lupus, it differs from it 
in the entire absence of the characteristic lupous tubercles, 
and of the tendency to ulceration ; in the manner of heal- 
ing in the center by a scar in which no relapse takes 
place ; in its superficial situation in the skin ; in the 
purulent matter that can be squeezed out from between 
its papilla? ; and in the relatively late time of life at 
which it appears. From syphilis it differs in its more 
chronic course ; in the absence of a wall of infiltration 
about it; in its color; and in showing no tendency to 
break down and ulcerate. 

Treatment. The growth may be curetted away, and 
the wound afterward treated with pyrogallol as in lupus. 
Or it may be destroyed by the galvano-cautery or by elec- 
trolysis. Or it may be covered with a twenty-five per 
cent, salicylic acid creosote plaster. Crocker advises the 
use of this plaster, to be followed with the fuming nitrate 
of mercury applied with a piece of wood. I have found 
the plaster sufficient in itself. Or it may be destroyed by 
any powerful caustic, but it must be destroyed entirely or 
it will crop out again. 

Prognosis. The disease is more easily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumeurs Folliculeuses. See Molluscum sebaceum. 

Tyloma, sen Tylosis. See Keratosis palmaris et plantaris. 

Tylosis Linguae. See Leucoplakia. 

Ulcers. Ulceration is a symptom common to many dis- 
eases, such as lupus, syphilis, scrofulodermata, and other 



ULCERS. 591 

destructive processes. For these the reader is referred to 
the sections treating of the disease of which they form a 
part. I shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological 
clinic, and that are usually called varicose ulcers. They 
are located most often over the anterior surface of the leg 
and on its lower half. They may be superficial or deep. 
They are irregular in shape with sloping or undermined 
edges, and with a more or less wide zone of redness and 
infiltration of the skin about them. Their bases may be 
covered with flabby granulations ; or be smooth and glazed, 
with thin, scanty secretion ; or they may discharge a great 
deal of sero-purulent matter. Some of them bleed read- 
ily, some do not. There may be but one ulcer, or there 
may be several of them. One or both legs may be af- 
fected. The ulcers may be small, or so large as to encir- 
cle the leg and occupy more than half its length, and they 
may attain this size either by gradual extension of them- 
selves or by the junction of several ulcers. They begin not 
infrequently as a number of small shelving ulcers on a red 
and densely infiltrated base. These enlarge rapidly and 
form a large ulcer. The patient complains of more or 
less spontaneous pain, and the ulcers are often very tender. 
The foot and leg are sometimes greatly swollen and feel 
brawny. It will be noted that the foot and leg are marked 
with dilated veins, and varicosities can be felt sometimes 
like wbip-cords under the skin. The deep veins are gen- 
erally swollen at the same time, though they cannot be 
felt so readily. Usually both legs are affected. 

Etiology. These ulcers are predisposed to by stand- 
ing for hours at a time, and it is standing in one position 
that is particularly obnoxious. It is therefore in car- 
drivers, blacksmiths, cooks, and those following similar 
occupations that ulcerations are prone to occur. A loaded 
condition of the portal circulation and constipated bowels 
also favor varicosities and the occurrence of ulceration. 
On account of the chronic, congested condition of the leg, 
some slight traumatism that in the normal state would 
produce hardly appreciable damage will be followed by 
a breaking down of the tissues and an ulcer. 



592 DISEASES OF THE SKIN. 

Diagnosis. It is most important to diagnose a varicose 
ulcer from one due to syphilis, as they require different 
treatment, and have a different prognosis. The syphilitic 
ulcer is usually located upon the upper half of the leg, and 
toward its posterior surface, or about the knee. It has an 
infiltrated border, but by no means as broad a one as the 
varicose ulcer. It lacks the marked inflammatory symp- 
toms of the varicose ulcer, and is "punched-out looking" 
with perpendicular ridges. It is round, or, if formed by 
the coalition of several softened tubercles, it will have a 
scalloped edge, indicating its origin from several distinct 
lesions. As a rule, it is quite painless, and there are several 
ulcers on one leg, the other being free. 

Treatment. If we can confine our patient absolutely 
to bed, and keep the leg snugly and evenly bandaged, the 
ulcers will heal under simple dressings. This we cannot 
do with most of our cases. Bandaging the leg from the 
toes to the knee is an essential in their successful manage- 
ment, an ordinary roller-bandage being used as long as 
any greasy applications are made. In ulcers connected 
with varicose veins, after acute symptoms have subsided, 
bandaging from the toes to the knee with a rubber band- 
age is excellent. So too in all ulcers is the continuous 
bath with warm water, or by means of cloths wrung out 
of hot water, frequently renewed and covered with oiled 
silk. 

One of the oldest and best treatments for ulcers is to 
touch them daily with balsam of Peru and cover them 
with oxide of zinc ointment, or, better, with Lassar's 
paste. Dry dressings for the ulcer are preferable to 
greasy applications, and for this we may use iodoform, 
iodol, aristol, subnitrate or subiodide of bismuth, or der- 
matol, or any of the later powders. If there is any eczema 
or dermatitis about the ulcer, it is requisite to cover the 
powder and the whole patch with some mild or stimulat- 
ing ointment according to the state of the skin. In this 
case the ulcer must be dressed once or twice a day. If 
there is not much dermatitis, we can dispense with the 
ointment, and dress the leg antiseptically and leave it for 
several days. Applications of nitrate of silver may be 



ULERYTHEMA. 593 

used to stimulate an atonic ulcer or to smooth clown exu- 
berant granulations. Strapping with adhesive plaster is 
another excellent means of treating ulcers upon not 
very much inflamed bases. Skin-grafting, according to 
Thiersch's method, is the most prompt and sometimes the 
only way to cause large ulcers to heal. For further surg- 
ical treatment of ulcers text-books on surgery must be 
consulted. 

Ulcer, Oriental. See Aleppo boil. 

Ulcer, Perforating, of Foot. See Perforating ulcer of 
foot. 

Ulcer, Tropical Phagedenic. This is an ulcer secondary 
to a lesion of the skin that occurs in the tropics, and is 
marked by rapid extension and gangrenous destruction of 
tissues. It may be mild or malignant in its course. The 
latter eats deeply, involving even the bones. 

Ulcus Rodens. See Epithelioma. 

Ulcus Grave. See Fungous foot of India. 

Ulerythema. This is the name proposed by Unna for 
those diseases in which there is a more or less persistent 
erythema upon which follows cicatrization by a process of 
absorption of inflammatory infiltration, and without ulcera- 
tion. Under this heading comes lupus erythematosus. 
Ulerythema sycosiforme 1 and ulerythema ophyrogenes 2 are 
two other varieties of this form of disease. They bear a 
resemblance to the "folliculitis decalvans" of the French. 
They both affect hairy regions, the first having a predilec- 
tion for the beard, and the second for the eyebrows. In 
their course they present symptoms somewhat like sycosis, 
but differ from that disease in causing permanent bald 
patches, and the destruction of the skin so as to form 
cicatrices. 

Ulerythema acneiforme is the name given by Unna 3 to 
a purely local, probably parasitic, disease of the skin 
which is limited to the neighborhood of individual hair 

l Monatshefte f. prakt. Dermat., 1889, ix., No. 3. 

2 Ibid., No. 5. 

3 Internat. Atlas of Rare Skin Diseases, No. 1. 



594 DISEASES OF THE SKIN. 

follicles. It begins as an inflammatory erythema, which, 
after persisting for some time, leads either to the forma- 
tion of a well-marked cornification of the cuticle and 
comedones, or to cicatricial atrophy. 

It differs from acne in beginning on the middle of the 
cheek and margin of the auricle ; in extending to the 
hairy scalp ; in being primarily an inflammatory ery- 
thema ; in an absence of suppuration, and in atrophy 
occurring without suppuration. It differs from acne ne- 
crotiea in complete absence of necrosis, suppuration, and 
ulceration ; in prominence of comedones ; and in having 
no resemblance to variola in its scar. 

Uridrosis. Synonym : Sudor urinosis. By this is meant 
the excretion by the sweat pores of sweat loaded with the 
constituents of the urine, specially urea. The sweat then 
often has a urinary odor, and deposits crystals of urates 
upon the skin. It is always a complication of some grave 
general disease. 

Urticaria. Synonyms : Cnidosis ; (Fr.) Urticaire ; (Ger.) 
Nesselsuch, Xesselauschlag, Porcellanfriesel ; (Eng.) Nettle- 
rash, Hives. 

An acute or chronic disease of the skin characterized by 
the appearance of wheals. This usually trivial affection, 
so common as to be a matter of every-day occurrence, at 
times may assume grave symptoms, or entirely nonplus 
us by its persistency. It may run an acute or chronic 
course. 

Symptoms. The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of wheals — that is, firm, flat, circumscribed ele- 
vations of the skin which are at first pink, and then white. 
They may remain pink. They may be round, oval, annu- 
lar, or elongated, and are always surrounded by a red 
areola. They vary in size, sometimes being no larger than 
the head of a pin, and sometimes of the diameter of an 
inch. They show no tendency to group, but are irregu- 
larly disseminated over the whole body. Though they are 
not symmetrical in distribution, both sides of the body are 
affected at the same time, and they show some preference 



URTICARIA. 595 

for the extensor surfaces of the arms and legs. They itch, 
burn, and tingle, and are always scratched. They are 
ephemeral, each lesion lasting but a short time — from a few 
minutes to a day. Exceptionally some wheals will last 
several days. New lesions crop out as old lesions fade, 
and thus the eruption is continued. The mucous mem- 
branes are often affected at the same time with the skin ; 
and if the pharynx is attacked there may be suffocative 
symptoms. The duration of the disease as commonly met 
with is but a few days, and not infrequently the wheals 
may be entirely absent during the day, to break out again 
at night. Very often when the patient is seen by the 
physician, he can find nothing but scratched papules. But 
the patient will tell him that when he is undressing, or is 
warm in bed, the itching becomes unbearable, and lumps 
looking like mosquito-bites break out upon him. The skin 
of a patient with urticaria is very irritable, so that a sharp 
tap upon it or drawing the nail across it will produce a 
wheal. 

The outbreak of the disease may be sudden without con- 
stitutional disturbance, or there may be some burning and 
tingling of the skin before its appearance. Or there may 
be some febrile movement, and some evident disturbance 
of the digestion, such as vomiting or dyspeptic symptoms. 
When the disease is cured the lesions disappear without 
desquamation, and leave no trace. Such is the acute form. 

Chronic urticaria differs from the acute form mainly in 
its duration. Instead of recovery taking place in a few 
days or weeks, its course is one of months and years. 
Sometimes the outbreaks of the eruption show marked 
periodicity, coming out at stated intervals after pauses of 
complete immunity. The eruption is generally not so ex- 
tensive in the chronic as in the acute form. If the itch- 
ing has been very severe and the scratching proportionally 
excessive, the skin may become pigmented, as in other 
chronic pruriginous diseases. 

The wheals assume different appearances in different 
cases, and different adjectives are used to express the 
varying pictures. It is not necessary to burden the mind 
with these, though they are convenient for descriptive 



596 DISEASES OF THE SKIN. 

purposes. Thus we have urticaria tuberosa seu gigans, 
where the lesions are unusually large ; urticaria, bullosa, 
where the wheals are surmounted by bulla? ; urticaria 
hemorrhagica, where hemorrhage into the wheals occurs; 
urticaria aedematosa, probably the same as acute circum- 
scribed oedema or acute angeioneurotic oedema, where the 
wheal occurs in locations in which the subcutaneous tis- 
sues are lax, as about the eye, nearly closing it, or on the 
tongue, causing it to swell enormously and threaten suffoca- 
tion ; urticaria papulosa, or lichen urticatus, where the wheals 
are small, a form common about the buttocks of children. 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal may 
readily be excited by local irritation. Urticaria perstans 
simply refers to the persistent character of the single 
lesion. Urticaria maculosa is the name proposed by 
Fournier for that form in which the wheal remains red. 

Etiology. The causes of the disease are more numer- 
ous than the forms it may assume. Most of the acute 
and many of the chronic cases are dependent upon irritat- 
ing ingesta, such as shell-fish, strawberries, cheese, pickles, 
mushrooms, pork, sausages, even mutton in some, and 
almost anything in other people, it being largely a matter 
of idiosyncrasy ; medicinal substances, such as quinine, 
cubebs, copaiba, salicylic acid, opium, and other drugs. 
The rupture of hydatid cysts has been followed by urti- 
caria. Dyspepsia in its various forms, and constipation, 
are common factors, especially in chronic urticaria, as are 
intestinal worms in children. So also at times may be 
disorders of the liver, uterus, and ovaries. Some very 
severe cases occur during pregnancy. Gout, rheumatism, 
malaria, and functional or organic diseases of the nervous 
system will be found at the bottom of many cases of 
chronic urticaria. 

Not only do we have internal causes producing the dis- 
ease, but also external causes, such as contact with the 
jelly-fish ; crawling of caterpillars ; the action of cold, or 
sudden changes of temperature ; the galvanic current ; and 
bites of insects. Urticaria is a common accompaniment 
of scabies and pediculosis. 



URTICARIA. 597 

Pathology. Urticaria is due to a vasomotor disturb- 
ance. At first there occurs a spasmodic contraction of the 
vessels of a circumscribed area of the skin, which is fol- 
lowed by paralytic dilatation of the vessels and retarda- 
tion of the circulation. Serous exudation ensues, forming 
the wheal, which at first is pink, and then becomes white, 
on account of the pressure of the fluid forcing out the 
blood from the central parts of the wheal. When the 
paresis ceases, the serous exudation is absorbed and the 
part returns to its normal condition. T. C. Gilchrist 1 
does not believe in the vasomotor theory of the disease. 
He thinks that it is an inflammation of the skin due to 
the escape of some toxin from the blood into the derma. 

Diagnosis. The occurrence of wheals is pathogno- 
monic of urticaria, as they occur in no other disease. 
When they are present there is no difficulty in diagnosis. 
When they are not present and we find only scratch-marks 
we have to decide whether we have to do with urticaria or 
eczema, scabies, pediculosis, or dermatitis herpetiformis. 
Eczema differs from urticaria in the tendency its lesions 
have to run together and form patches. It never could 
be so generally distributed without presenting some char- 
acteristic patches. Scabies shows scratch-marks on the 
hands and feet, between the fingers and toes, in the axilla?, 
about the umbilicus, and on the breasts of the female and 
the penis of the male. The cuniculi may be found in most 
cases. Pediculosis shows long parallel scratch-marks over 
the back, between the shoulders, along the outside and 
inside of the limbs where the seams of the clothing come, 
and about the waist. Dermatitis herpetiformis presents 
grouped lesions, which usually are vesicles, but may be 
papules. Erythema of papular or tubercular variety may 
resemble urticaria, but it is a markedly symmetrical dis- 
ease, and burns rather than itches. 

Treatment. In acute urticaria the administration of 
a prompt cathartic or saline laxative will usually cure the 
disease if due to some irritating ingesta. Emetics may 
be useful, if we see the case before stomachic/ligestion is 
ended, but in most cases we are called in when it is too late 
1 Journ. Amer. Med. Assoc, 1896, xxvii., 1222. 



598 DISEASES OF THE SKIN. 

for them to be of service. Saline laxatives, mineral acids, 
rhubarb and soda, salol, resorcin, or other intestinal dis- 
infectants are of service in the more chronic cases. Of 
course, if the eruption is due to the ingestion of drugs, 
they must be stopped. 

In chronic cases, besides medicinal treatment we must 
regulate the diet, studying each case by itself. It is often 
well to put the patient on a strictly milk diet for a few 
days, and then add other articles with care. Alcoholics 
in all forms, and especially beer or other malt liquors, 
should be prohibited. If the gouty or rheumatic diathesis 
is at the foundation of the trouble, it must be combated. 
If the outbreak shows marked periodicity, sulphate of 
quinine may do good. Salicylate of soda sometimes does 
good service even when there is no evident rheumatic 
tendency. In fact, we must endeavor in every way to 
get our patient into a normal state of health. The most 
difficult class of cases are those in which a neurosis alone 
seems to be the cause. Then belladonna, atropia, arsenic, 
the bromides, antipyrine, phenacetine, and galvanism may 
be tried. Pilocarpine, wine of antimony, colchicum, 
ergot, are also commended. In very obstinate cases the 
patient should be sent away from home and relieved from 
all business cares. 

Local treatment is of great service in allaying the itch- 
ing, but it will not cure the disease. The parts may be 
sponged with alkaline lotions, such as a teaspoonful of 
baking-soda to a hand-basinful of water. Sometimes more 
relief is obtained bv an acid solution, such as vinegar, 
pure or with water. Carbolic acid in vaseline, or alcohol 
and water, is sometimes very efficacious. In vaseline, ten 
per cent, strength is sufficient ; in lotion-form we may 
use, to the adult skin, one to two drachms to the ounce, 
directing the patient to dab and not rub it on the skin. 
Hardaway prefers using the acid in a spray, two to four 
drachms to the pint, with one ounce of glycerin. To 
each atomizerful ten drops of oil of peppermint may be 
added to increase its antipruritic qualities. Menthol, one 
to ten per cent, in alcohol or almond oil, is said to be effica- 
cious. Crocker speaks highly of liquor carbonis detergens, 



URTICARIA. 599 

3j to liv; terebene, 3iv to §iv ; and equal parts of sanitas 
and water. Salicylic acid, twenty grains to the ounce of 
castor oil, is good, but disagreeable. Camphor and chloral 
hydrate, each from half to one drachm, rubbed together 
and added to one ounce of starch or ungt. simplex, is an- 
other good antipruritic. Chloroform dabbed or sprayed 
on renders prompt relief. Baths are sometimes of use. 
Having the patient take a warm bath containing either 
two to six pounds of bran, or a quarter to half a pound 
of bicarbonate of soda, or an ounce of nitromuriatic acid, 
just before going to bed ; then drying the skin by wrap- 
ping in a warm sheet and patting the skin dry ; then 
smearing the skin with a film of vaseline and dredging 
over this cornstarch powder, will often give him a good 
night's rest. 

Prognosis. The vast majority of cases of urticaria 
recover in a few hours or days. The chronic cases often 
are most obstinate, but unless some severe nerve lesion is 
at the bottom of the case, they can be cured by patient 
and persevering effort. 

Urticaria Pigmentosa. Synonym: Xanthelasmoidea. 

Symptoms. This is not an ordinary urticaria, that, on 
account of its chronic course and the scratching to which 
it has been subjected, leaves more or less pigmentation of 
the skin. Such a condition of things is not infrequently 
seen. Urticaria pigmentosa begins within the first six 
months of life by an eruption of wheals or tubercles, which 
at first are about the size of a split pea, and of a brownish 
or yellowish-red color, with a pink areola. Later they 
may increase in size, or several may coalesce to form a 
large one, and assume a yellow or buff color. These 
wheals appear in crops, and run a very chronic course, 
each one persisting for weeks or months. They then 
shrink, become softened, and disappear, leaving brownish 
pigmentation. As the course is chronic, we will find on 
the patient wheals or tubercles of red or yellow color, of 
various sizes, some hard and tense, some soft and wrinkled, 
and brown stains of the skin. . Ordinary urticarial evanes- 
cent wheals will sometimes be found, and rubbing of the 



600 DISEASES OF THE SKIN. 

apparently stationary tubercles will cause some of them 
to enlarge. The wheals are most often located on the 
trunk and neck; then on the limbs, face, and head; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching- may or may not be present. After a number of 
years the wheals will no longer come out, and recovery is 
generally complete at about the age of puberty, though 
the disease may last much longer than that. Morrow ' 
has reported one case of over twenty years' duration. 
The majority of the cases, according to Crocker, occur in 
boys. We know no cause for the disease, and thus far 
treatment has been in vain. 

Vaccinal Eruptions. The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation ; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due 
not to any bad quality of the virus, but either to some 
accidental infection or to idiosyncrasy. Sometimes an 
ulcer will form at the site of the vaccination ; or starting 
from this point we may have a dermatitis, cellulitis, 
lymphangitis, erysipelas, abscess, or furuncle. At times 
exuberant granulations, or what is called an infective 
granuloma, may develop upon the seat of the vaccination. 
An outbreak of impetigo contagiosa may originate from 
inoculation, the pus of the sore becoming transferred to 
other parts by the finger-nails ; or an eczema or psoriasis 
maybe set up by the irritation of the sore, just as they 
may follow other affections of the skin. 

General eruptions usually appear, according to Harda- 
way, after the ninth or tenth day of vaccinia, and assume 
an erythematous, papular, or papulo-vesicular character. 
The roseola vaccina of Hebra is an erythematous eruption 
of macular character, commencing usually upon the arms, 
and sometimes spreading over the whole body. It is ac- 
companied in some cases with slight rise of temperature 
for a few hours. It disappears and leaves no trace. 
1 Journ. Cutan. and Gen.-Urin. Dis., 1895, viii., 445. 

















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3 -^ 

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VARIOLA. 601 

We may also encounter erythema multiforme and urti- 
caria complicating vaccination. It is possible that a bul- 
lous eruption may occur, but this is very rare. Syphilis 
also may be inoculated in arm-to-arm vaccination. Gan- 
grene may occur in the sore and other accidents. All of 
these are rare. 

Varicella, or Chicken-pox, is an eruptive fever of mild 
grade, with an incubative period of two weeks. It is 
characterized by an outbreak of a greater or less number 
of red papules and clear vesicles, of pinhead to pea size, 
and varying shape, that come out in crops. A long vesicle 
is very characteristic of this eruption, as is the location of 
the vesicle or pustule to one side of the areola. The vesicle 
can be easily ruptured. There is usually only slight consti- 
tutional disturbance. The mucous membranes may be 
involved. 

Varicella G-angrsenosa. See Dermatitis gangrenosa in- 
fantum. . 

Variola, or Smallpox, is an acute contagious fever with an 
incubative period of about two weeks. It is characterized 
by very severe prodromal symptoms, such as headache 
and intense pain in the back and legs, and the appearance, 
usually on the third day, of an eruption of minute red 
spots that soon change into small, round, hard, shotty 
papules. The eruption is first seen on the face about the 
forehead and mouth and on the neck and wrists. In about 
twenty-four hours after its first appearance vesicles form 
upon the papules, and attain their full development by 
about their fifth day. They then are umbilicated, are 
located upon a hard base, and have a well-marked areola. 
Now they change into pustules, and a well-marked second- 
ary fever attends the change. After about four or five 
days the pustules dry up into crusts, and afterward these 
fall, leaving pitted cicatrices in many places. The mucous 
membranes are commonly involved. In varioloid, modified 
smallpox, the constitutional symptoms as well as the erup- 
tion are of much milder grade. 

Diagnosis. Variola bears a resemblance to the pus- 



602 DISEASES OF THE SKIK 

tular syphilide ; for the differential diagnosis, see the 
'• pustular syphilide." Acne and pustular eczema both 
have lesions resembling those of variola, but are limited 
to certain regions, and are not general eruptions. Vari- 
cella and papular erythema have been mistaken for 
variola. In its earlier stages the diagnosis of variola is 
very difficult. In pronounced cases, on the other hand, 
the diagnosis is easy. 

Varus. See Acne. 

Vegetation dermique. -v 

Vegetations. V See Verruca. 

Venereal Wart. > 

Verbrennung. See Dermatitis ambustionis. 

Verruca. Synonyms : (Fr.) Verrue ; (Ger.) Warze ; 
Wart. 

These exceedingly common papillary outgrowths assume 
various appearances, to which descriptive names have been 
given. Thus we have verruca vulgaris, or the wart so 
often seen on the hands of children and young people. 
These vary in size from that of a hemp-seed to that of a 
split pea, or larger where two or more become aggregated. 
They are sessile, hard, conical, with flattened tops. They 
may be smooth, or uneven, showing their papillary for- 
mation. They may be of the color of the skin, or some 
shade of yellow, brown, black, or green. There may 
be a number of them, and they may be isolated or aggre- 
gated. They may occur elsewhere than on the hands. 
Verruca digitata is a wart in which the papilla? are 
separated distinctly from each other. These occur in 
groups, and are often seen on the scalp. Verruca filijormix 
is a wart in which the papillae are not only distinct, but 
fine, almost thread-like. Each papillary outgrowth stands 
by itself. These are soft to the touch, and occur on the 
face, eyelids, and neck. Verruca plana is a flat wart, but 
slightly elevated, and varying in size from that of a 
pinhead to a half-inch in diameter. These sometimes occur 
in large numbers. In young people they occur upon the 



VERRUCA. 603 

face and backs of the hands, and may or may not be 
pigmented. In old people they occur on the trunk 
and arms and are pigmented, and are called verruca senilis 
or seborrheal warts. Verruca acuminata, also called 
condyloma acuminata, vegetation dermique, spitzen ivarzen, 
and venereal or moist wart, is met with in the anal 
and genital regions of both sexes, as also in the axillae, 
under the hanging breasts, in the umbilicus, and between 
the toes. These are vascular, sessile or pedunculated, 
and composed of a great number of closely aggregated 
projections of various shapes. On exposed situations they 
are dry and of the color of the skin ; while in locations 
that are moist — that is, between the skin-folds — they 
are covered with a whitish puriform secretion, and, unless 
kept very clean, they emit an offensive odor. They some- 
times attain to an immense size. 

Etiology. We do not know the cause of warts. 
They are regarded by some as contagious, and parasites 
have been isolated and declared to be the morbific agents. 
They have been produced by inoculation. They occur 
more frequently in the young than in the old, and may 
be congenital. Venereal warts are traceable to irri- 
tating discharges, but not by any means always to a 
gonorrhoea. They are undoubtedly contagious. 

Pathology. Warts concern the rete mostly, being 
markedly downward and upward growths of its cells. The 
papillae beneath the wart are flattened. The corneous layer 
of the skin is hypertrophied, but less compact than normal. 

Treatment. The treatment of most all warts is prompt 
and efficient by means of the curette, scraping them off 
while the skin is slightly stretched. If there is any doubt 
about their returning, their bases may be touched with 
iodine or nitric acid. Generally simple scraping is suffi- 
cient. The wart often is thus turned out of the skin entire, 
like a pea from a pod. No scar is left, because the corium 
is not wounded. Electrolysis may be used. The digitate 
and filiform warts may be snipped off with the scissors. 
If operative interference is refused, the warts may be re- 
moved by painting with tincture of iodine ; or a saturated 
solution of salicylic acid ; or a twenty per cent, solution 



604 DISEASES OF THE SKIN. 

of resorciu ; tincture of thuja ; or nitric or glacial acetic 
acid. G. W. Fitz 1 says that painting them daily with a 
ten per cent, solution of chrysarobin in traumatiein, after 
rubbing them down with fine sandpaper, will remove them 
in a week or so. In the country children's warts are re- 
movable in some cases by the application of the juice of 
the common milk-weed. Venereal warts may be removed 
by keeping them clean and dry, and painting them with 
liq. plumbi subacetatis, or a solution of the perchloride or 
persulphate of iron ; or dusting them with salicylic acid 
and starch, or with boric acid. Chromic acid is a powerful 
caustic. Caustic potash is not a safe agent to use, unless 
care is had to limit its action by a ring of wax about the 
wart. The galvano-cautery may also be employed. 

It is said that warts may be removed by internal treat- 
ment. Sulphate of magnesia, two or three grains to a 
child and half a drachm to an adult, three times a day, is 
one remedy. Besnier has tried this method in a number 
of cases with absolute unsuccess. Tincture of thuja occi- 
dentals is said to be efficacious. Crocker thinks he has 
seen cures effected with full doses of nitromuriatic acid, 
while others advocate arsenic. 

Warts very often disappear of themselves, and no one 
has ever seen them fall. 

Verruca Necrogenica. See Tuberculosis verrucosa cutis. 

Verrue. See Verruca. 

Verrue Telangiectasique. See Angiokeratoma. 

Verruga, Endemic. See Yaws. 

Verruga Peruana. This disease is said to occur in the 
narrow, hot valleys of Peru. It begins as a fever resem- 
bling malaria, accompanied by anaemia, pains in the joints, 
neuralgia, and swelling of the liver and spleen. The 
patient may die in this stage. If he survives, the warts 
follow the fever. They may appear suddenly without the 
prodromal fever. They may be miliary in size, and rosy 
and translucent; or larger, forming dull horny papules; or 
nodular in size, when they may be complicated with furun- 
1 Boston Med. and Surg. Journ., 1899, cxl., No. 26. 



XANTHOMA. 605 

cles. They are scattered over the body. They may un- 
dergo spontaneous involution. A special bacillus is sup- 
posed to be the cause of the disease. They are to be scraped 
off with a curette. 

Vibices. See Purpura. 

Vitiligo. See Leukoderma. 

Vitiligo Capitis. See Alopecia areata. 

Vitiligoidea. See Leucoderraa. 

SI',} *.V~ 

Warzenkrebs. See Carcinoma. 
Warzenmal. See Nsevus verrucosus. 

"Wash-leather Skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. 
It occurs, as a rule, in patients suffering from diseases which 
directly or indirectly affect either the trophic or the sensory 
nerves, such as renal disease, phthisis, erysipelas, and 
hemiplegia. It sometimes precedes the occurrence of bed- 
sores. 

Weichselzopf. See Plica. 

Wen. See Sebaceous cyst. 

Whelk. See Acne. 

Xanthelasma. See Xanthoma. 

Xanthoma. Synonyms : Xanthelasma ; Vitiligoidea ; 
Molluscum cholesterique ; Fibroma lipomatodes. 

A peculiar disease of the skin characterized by the ap- 
pearance of discrete patches, or tubercles, of chamois or 
lemon-yellow color. 

Symptoms. Xanthoma may assume one of two forms : 
Xanthoma planum, or Xanthoma tuberosum or tuberculatum. 
In the former we meet with flat, chamois-leather-like, or 
lemon-yellow plates that are either slightly raised above 
the level of the skin, or not at all raised. They vary in 
size from an eighth of an inch to an inch in their long 



606 DISEASES OF THE SKIN. 

diameter, feel soft and smooth to the touch, and when 
pinched between the fingers no infiltration of the skin is 
perceptible. They are irregular in shape, tending to form 
elongated figures. When in patches, they feel almost 
velvety, and when examined with a lens they are seen to 
consist of an aggregation of small granules, many of which 
have a central pinkish punctum. 

Xanthoma tuberosum exhibits lesions of the same color 
as does the plain variety, or they may be reddish yellow, 
but they are raised above the skin and may attain to a 
large size. They are soft, smooth, round or oval, with 
telangiectases over them when small. When large, they 
are firmer and more irregular in shape, being made up by 
aggregation of a number of smaller tubercles. Xanthoma 
multiplex is the name applied to cases in which both varie- 
ties are present. In all forms, unless there is jaundice, 
the skin between and about the lesions is normal in color. 
Most cases give rise to no subjective symptoms, but there 
may be some itching or burning. If the disease occur 
upon the palms or knees, it may cause discomfort or even 
pain on kneeling or handling objects. 

The favorite site of xanthoma planum is in the upper 
eyelid, where they are not infrequently seen. There they 
commence at the inner canthus, most often of the left eye, 
and spread in a semicircle about the eye, while shortly 
afterward a smilar growth begins on the right upper eyelid. 
Next in point of frequency to the eyelids, they occur upon 
the flexures and mucous membranes. Xanthoma tuberosum 
is most frequently seen upon the knees, elbows, knuckles, 
and other points of pressure, the trunk being not so much 
affected. Symmetry is generally observed. Xanthoma 
multiplex is often very widely distributed. Sometimes 
the lesions run in streaks, or, as in Hardaway's case, 1 are 
arranged like a zoster. The following case reported by 
me 2 is one of the most extensive on record : 

Michael M.,aged five years, was admitted to my service 
at the Randall's Island 'Hospital in May, 1890*. From 
the child's sister I have been able to gather the following 

1 St. Louis Courier of Med., October, 1884. 

- Joiirn. Cutan. and Gen.-Urin. Dis., 1890, viii., 241. 



XANTHOMA. 607 

imperfect history : The eruption appeared when the child 
was three months old, without any antecedent disease, and 
came out all over the body at the same time. It is thought 
that no new lesions have appeared since then ; that there 
has been change in the size of the lesions, and that some of 
they have disappeared. The boy is said to have always 
been well, to have played about like other boys, and never 
to have been jaundiced. 

Examination of the boy reveals a very extraordinary 
condition of affairs : the whole body of the boy is occu- 
pied by a disseminated efflorescence, no part being spared 
except the hands, feet, and scalp. The lesions are about 
the size of a split pea or a little smaller, are soft to the 
touch, and have a central depression. Upon the face, 
trunk, shoulders, and lower part of the legs they are dis- 
crete, and scattered about without any particular arrange- 
ment. Upon the extremities the lesions are crowded into 
patches of various sizes and shapes, with normal skin be- 
tween them. Even in the patches the lesions are distinct. 
They touch each other but do not coalesce. The distribu- 
tion of the lesions and of the patches is quite symmetrical. 
The color varies from a lemon yellow in the discrete lesions 
on the shoulders to an orange yellow in the patches. About 
the joints the color is reddish brown. 

In the right eyelid are well-marked, typical xanthoma- 
tous patches of chamois-leather color. The lower lid is 
occupied by one continuous patch running from the inner 
to the outer can thus. On the upper lid there is a small 
tumor. The left lid is but very slightly affected. Upon 
the back of the neck and the upper part of the back 
are a number of light-brown pigmentary spots, which his 
sister says are the remains of some lesions that have 
disappeared. Scattered about the trunk are a number 
of depressed scars, apparently the remains of a recent 
varicella. 

The boy is very thin, of blonde type, and the skin is 
pale. Apart from this there is nothing abnormal. His 
appetite is good, his digestion is in fine condition, and his 
urine contains neither albumin nor sugar. Upon the left 
buttock there is one vascular nsevus. 



608 DISEASES OF THE SKIN. 

Under the name of Pseudo-xardhom elastique E. Bodin 1 
has described an eruption of pinhead-sized, oval or round, 
pale-yellow lesions that occurred in symmetrical patches, 
about which were scattered single lesions. The surface 
of the patches was smooth or slightly granular. They 
occurred on the lower part of the abdomen, clavicular 
region, anterior wall of axillse, inside of arm, forearm, and 
thighs. 

The skin in xanthoma is not alone affected. Xantho- 
matous bodies are found in the liver, mucous membranes, 
and tendons. The disease is progressive for a time, and 
then may remain stationary for years, or may undergo 
spontaneous resolution. 

Etiology. Xanthoma occurs much more frequently in 
adults than in children, and that form that occurs in the 
eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the dis- 
ease is sometimes hereditary. But we really do not know 
as yet what is the cause of the disease, though various 
theories have been advanced. Hepatic diseases ; diabetes ; 
diathetic conditions of various kinds ; migraine ; embryonic 
cells left in the skin — each have been found in connection 
with one or many cases. Hardaway may not be wrong in 
his idea that it is a diathetic disease, and that when it occurs 
with jaundice it is because the same tubercles have been 
deposited in the liver as in the skin, and the jaundice is 
secondary to them. 

Pathology. It is a connective-tissue new growth con- 
taining an abundance of fat. Between the connective-tissue 
bundles the so-called "xanthoma cells" are found. The 
color of the lesions is due to fat-globules. (Heitzmann.) 
S. Pollitzer 2 believes that xanthoma palpebrarum is due to 
the degeneration of embryonically misplaced muscle fibers. 

Diagnosis. The diagnosis of this unique disease is 
made by the occurrence of chamois-leather-colored soft 
plates or tubercles, such as occur in no other disease. 
Milium may bear some slight resemblance to xanthoma, 

1 Ann. de derm, et de svph., 1900, i., 1073. 
■ New York .Med. Journ., 1899, lxx., 73. 



XANTHOMA. 609 

but it is hard and firm, not soft and velvety, and white, not 
yellow. It is easily squeezed out after a prick through the 
skin over it, an impossibility in xanthoma. 

Treatment. In the way of treatment we have no 
sure resource save the knife and electrolysis. The latter 
is preferable. In so general a case as mine neither plan 
would be applicable. Besnier 1 reports good results from 
the administration of phosphorus in cod-liver oil, giving 
one milligramme per day, and increasing the dose each 
day by a quarter of a milligramme until three milli- 
grammes are taken. After fifteen days this is stopped and 
turpentine is given. Stern 2 tried this plan without suc- 
cess, but succeeded in removing patches of the disease from 
the eyelids by the use of a ten per cent, solution of corro- 
sive sublimate in collodion. Shepherd, of Montreal, saw 
one case recover after an operatiou for biliary calculi ; and 
McGuire removed one with monochloracetic acid. 

Xanthoma Diabeticorum. Besides the xanthoma just 
described, there is another form which is regarded as a dis- 
tinct affection, and called Xanthoma diabeticorum. 

Symptoms. It is an exceedingly rare disease, which 
differs from ordinary xanthoma in its more sudden devel- 
opment ; in disappearing sooner or later, perhaps to recur ; 
in the hardness of its lesions, which are never macular ; 
in the frequent absence of a yellow color ; in the presence 
of a certain amount of inflammation ; in the absence of 
jaundice and presence of diabetes mellitus ; in its more 
pruriginous character ; in avoiding the eyelids ; and in 
having its lesions about the mouths of the hair follicles. 
In factj it resembles ordinary xanthoma mostly in its loca- 
tion upon the elbows, knees, and other points of pressure, 
and in the general configuration of the lesions. In it we 
have conical papules with yellowish apices and pinkish-red 
bases. The lesions often disappear when the diabetes is 
relieved. The treatment should be directed to the dia- 
betes, which is at the foundation of the disease, and to the 
allaying of the itching. 

1 Joum. de Med. et de Chir., April, 1866. 

2 Berlin, klin. Wochenschr., 1889, xxv., 393. 



610 DISEASES OF THE SKIN. 



Xeroderma. See Ichthyosis. 



Xeroderma Pigmentosum. See Atrophoderma pigmen- 
tosum. 

Yaws. 1 Synonyms : Frambcesia ; Pian ; Parangi ; Ver- 
ruga ; Granuloma tropicum. 

This is a disease that occurs only in tropical countries. 
The stage of incubation lasts two to eight weeks and is 
without special symptoms. The stage of invasion, with 
more or less well-marked fever and rheumatic pain, which 
abate before the eruption appears, lasts one or two weeks. 
The eruption is preceded by enlargement and tenderness 
of the lymphatic glands, and consists of pinhead- to lentil- 
sized, slightly elevated papules on a broad base. The 
papules enlarge ; the epidermis splits and curls off from 
their centers, and exposes a yellowish point which develops 
into a fiat, moist, red or pink tumor, looking not unlike a 
raspberry. These tumors range in size from that of a split 
pea to that of a nut, are round or oval, discrete or coalesced 
into large irregular masses. The surface of the tumor is 
covered with a thin, yellowish, foul-smelling discharge, 
that dries into a crust, which may ultimately assume a 
rupia-form. In the mouth and in moist situations no crusts 
form, and the tumors will resemble mucous patches. They 
reach their full development in from two to four weeks, 
remain stationary for months, and then dry up and fall off, 
leaving a stain on the skin that eventually disappears. 
They may break down and ulcerate, involving both the 
adjacent soft parts and the bones. The tumors are not 
tender. The disease tends to recovery, but is subject to 
relapses. It is contagious, and one attack is protective to 
a certain extent. Death occurs in bad cases. There is a 
probability that the disease is syphilis modified by climatic 
and racial influences. It is supposed to be due to a specific 
micrococcus. 

Treatment. The treatment is the same as in syphilis — 
that is, by mercury and iodide of potassium. Locally, 
disinfectant and mercurial applications should be used. 

Zaraath. See Lepra. 

1 This account is condensed from Crocker. 



ZOSTER. 611 

Zona. See Zoster. 

Zoster. Synonyms : Zona ; Herpes zoster ; Ignis sacer ; 
(Ger.) Feuergiirtel, Giirtelkrankheit ; Shingles. 

An acute disease of the skin characterized by a unilat- 
eral eruption of groups of vesicles upon reddened bases 
scattered along the course of certain nerves. 

Symptoms. Zoster, like psoriasis, presents such marked 
lesions that once seen it is readily recognized when seen 
again. It occurs in the form of groups of vesicles seated 
upon red bases, and arranged along the course of nerves 
upon which there are ganglia. (Fig. 80.) The vesicles 
are at first filled with serum that afterward may become 
cloudy. They do not tend to break down of themselves, 
but are frequently ruptured by accident. The size of the 
groups varies greatly. There may be but a few vesicles or 
a large number of them closely crowded together. Some- 
times -a group is no larger than a three-cent piece, and 
sometimes it is several inches in its longest diameter. 
Sometimes the vesicles may run together and form blebs. 
The shape of the groups is always irregular. There may 
be but two or three groups or a score of them. In nearly 
all cases the disease is unilateral, though it is not uncom- 
mon for one or two groups to be found close to the middle 
line, on the side opposite to the site of the disease, and 
cases of double zoster occur, though very rarely and never 
on the same level. All the groups do not come out at 
once, but, as it were, by a series of outbreaks, the earliest 
ones to appear usually being those nearest the point of exit 
of the nerve. The eruption is usually at its height in a 
week, the vesicles drying up, forming a crust and falling 
off, leaving a red mark that soon fades. The whole dura- 
tion of the disease is from ten clays to three or four weeks. 

In many, if not most, cases the patient experiences 
neuralgic pain in the nerve along whose course the erup- 
tion is about to appear. This is sometimes wanting, and 
generally lessens or disappears when the eruption appears. 
Sometimes the pain is severe during the duration of the 
eruption, and after it is gone. Tender points may often 
be found over the points. of exit of the nerves, like those 



612 



DISEASES OF THE SKIX. 



found in neuralgia. In some patients there will be fever 
before the outbreak of the vesicles or the successive ap- 
pearance of new groups. The vesicular stage is preceded 
by an erythemato-papular stage. Very rarely some of 
the groups may abort at this stage. Exceptionally, zoster 
may occur on both sides of the body. In nearly all cases 
the disease does not recur. Exceptionally a patient may 
have several attacks of the disease. 

Most cases of zoster occur upon the trunk, and, it is 
said, especially on the right side. It also occurs upon the 
face, on branches of the fifth nerve, when it may involve 
the eye and produce blindness by destructive ulceration. 

Fig. 80. 




Zoster of arm. 



The neck may be affected, and with it the arm. The leg, 
too, may suffer. Generally the eruption does not reach 
further down than the elbow and knee, though it may 
occupy the forearm and hand, leg and foot. In rare 
instances the tongue and pharynx may be affected. Vari- 
ous names are used to designate the location of the erup- 
tion, such as zoster frontalis, ophthalmicus, cervicalis, in- 
tercostalis, genito-cruralis, and the like. 

In rare cases hemorrhage may occur into the vesicles, 
or they may be purulent from the start, or they may 
ulcerate, or become gangrenous. The neuralgia may con- 
tinue in old or debilitated subjects in so severe a manner 
as to threaten the exhaustion of the patient from pain and 






ZOSTER. 613 

loss of sleep. Or pruritus, hypersesthesia, or anaesthesia 
may be left for some time after the disappearance of the 
eruption. Or paralysis of motion may follow the attack, 
as well as atrophy of muscles. Scars will follow the dis- 
ease if ulceration has occurred. 

Etiology. Zoster occurs more often in children than 
in adults. Sex seems to have little influence. It follows 
upon injuries to nerves in some cases, and has been asso- 
ciated with caries of the ribs. It has been known to 
occur while the patient was taking arsenic. It occurs 
frequently in the damp, cold weather of the spring and 
autumn, so much so as to give rise to epidemics. Indeed, 
some regard the disease as infectious on account of the 
epidemic character it sometimes has. Some cases seem to 
arise from peripheral irritation of cutaneous nerves. A 
descending peripheral neuritis of the spinal ganglion is 
regarded by Crocker as the condition most frequently 
associated with the disease. In a great number of cases 
disease of the ganglia upon the posterior roots of the spinal 
nerves has been found post mortem. When the fifth 
nerve is affected, it is the Gasserian ganglion that is dis- 
eased. Zoster may arise from injury, as a wound of a 
nerve-trunk, and then we may have an ascending zoster, 
the first group being nearest the point of injury. 

Diagnosis. Zoster in most cases is readily recognizable. 
It differs from eczema in having larger vesicles that do not 
tend to rupture ; in its patchy character, the patches being 
located along certain nerve-trunks ; in the neuralgia that 
accompanies it ; and in the definite course that it runs. 
Herpes facialis >or progenitalis sometimes resembles zoster 
quite closely, but in them there will often be a history of 
previous attacks ; they will not occur so markedly as 
groups of vesicles upon one side alone ; and they will not 
be preceded by the same amount of neuralgia. By some 
authorities herpes and zoster are considered to be the 
same disease. 

Treatment. The most important part of the treat- 
ment of zoster is to prevent the breaking of the vesicles, 
and the possible ulceration that would follow and leave 
scars. To this end we should avoid ointments and use 



614 DISEASES OF THE SKIN. 

dusting powders, such as oxide of zinc, bismuth, starch, 
guaiacol, five per cent, with starch powder, or, what is 
better, we should paint the vesicles with flexible collodion 
with or without morphine, which sometimes seems to abort 
the formation of vesicles. It is also advisable to cover the 
eruption with a soft linen bandage to prevent rubbing. If 
the vesicles have become broken and ulceration has ensued, 
then we have to treat the ulcers on surgical principles. 

To relieve the pain of zoster the galvanic current gives 
the best results, one sponge electrode being placed over 
the spine, and a steel roller electrode attached to the other 
pole and passed around the groups for ten or fifteen 
minutes once or twice a day. A current-strength of two 
or three milliamperes may be used, and, if it can be done, 
the last application should be made just before going to 
bed. Other means arc hypodermics of morphine ; blister- 
ing over the root of the nerve ; guaiacol as mentioned 
above, and the use of the menthol cone or oil of pepper- 
mint. Phosphide of zinc, one-third of a grain every three 
hours, is thought by some to relieve the pain arid limit 
the eruption. For the persistent neuralgia that at times 
follows these cases, arsenic, or strychnine, iron, quinine, 
cod-liver oil, and a good nutritious diet are necessary. 
Opium may have to be given to allay pain and procure 
sleep. 

Prognosis. Most cases of zoster run a favorable course 
and get well of themselves. It is only in old or debilitated 
people that we need fear any serious results. There is 
always the possibility of the occurrence of ulceration and 
gangrene, though it is not to be expected in the vast 
majority of cases. The popular opinion that if zoster 
occurs on both sides at once and forms a girdle the patient 
will die, has no foundation in fact, as such an occurrence 
is unknown. 



APPENDIX. 



The following formulae are given as guides in the preparation of pre- 
scriptions for the treatment of skin diseases. Many, if not all of them, 
have been well tried and their value proved •: 

A. BATHS. 

Simple Water Baths: 

Cold 40°- 65° F. 

Cool 65°- 75° F. 

Tepid 85 c - 95° F. 

Warm 95°-100° F. 

Hot • • • 100°-110° F. 

Wet Pack. Wrap patient in a wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry,, and anoint 
with oil or ointment. Useful' to remove the scales in psoriasis and to 
diminish hyperaemia. 

Medicated Baths. To an ordinary bath-tubful, say thirty gallons 
of water, add for 

Bran bath . . . . . 2 to 6 pounds bran. 
Potato-starch bath . 1 pound starch. 

Gelatin bath . . '. 1 to 3 poundsgelatin. 
Linseed " . . . 1 pound linseed. 

Marshmallow bath . 4 pounds marshmallow. 

Size bath ■ 2 to 4 pounds size. 

These baths are useful in erythematous, itchy, and scaly diseases. In 
using bran it should be tied up in cheese-cloth bags before being 
put in the water. 

For an. alkaline bath add to bath, 

Bicarbonate of soda . ...... 2. to 10 ounces, or 

Carbonate of potassium .... 2 to 6 " or 

Borax .!.... 3 " 

These baths are useful in eczema, psoriasis, urticaria, prurigo, and 
pruritic diseases. 

For an acid bath add to bath, • 

Nitric acid . . .1 ounce, or 

Muriatic acid . . ■ 1 " 

, . Or may use of each . J " 

Of use in chronic pruritic diseases. 

615 



616 APPENDIX. 

Iodine Bath: 

To bath. 

Iodine £ to 1 drachm. 

Iodide of potassium, vel . . . . £ ounce. 

Liquor potassae 1 to 2 ounces. 

Glycerin 2 " 

Useful in scrofulous and squamous diseases. 

Bromine Bath; 

To bath. 

Bromine . . 2(J drops. 

Iodide of potassium 2 ounces. 

Same indications as iodine bath. 

To bath. 
Stilphuret of potassium 2 to 4 ounces. 

Used in scabies, chronic eczema, lichen, and psoriasis. 
Startin's Compound Sulphur Bath : 

To bath. 

Precipitated sulphur 2 ounces. 

Hyposulphite of soda 1 ounce. 

"Water 1 pint. 

Same indications as the sulphuret of potassium bath. 

Mercurial Bath: 

To bath. 

Bichloride of mercury 3 drachms. 

Hydrochloric acid 1 drachm. 

Water 1 pint. 

Used in pityriasis rubra and the syphilides. 

B. FOR INTERNAL USE. 

1. Turpentine Emulsion: 

R. 01. terebinthina?, n\x-xxx ; 0.66-2 

01. limonis, tt\,ij ; 1 

Mucilag. acacia?, ,^ss; 16 

Aquse destil., ^ss ; 16! M. 

Sig. A teaspoonful three times a day immediately after meals. 
One quart of barley-water to be drunk during twenty-four 
hours. (Crocker.) 
Used in psoriasis, eczema, and hyperemias. 

2. Mixed Treatment : 
a. R. Hydrarg. bichlor., 

Potass, iodid., 
Tinct. cinchon. co., 
Aqua? destil., 
Sig. One drachm in water t. i. d. one hour after meals. (Taylor.) 



? r - j-».i ; 


06-.2 


3iv-viij ; 


16-32i 


.=?J'J»s ; 


112 


z ss; 


16 M 



APPENDIX. 



617 



b. R. Hydrarg. biniod., 
Amnion, iodid., 
Potass, iodid., 
Syr. aurant. cort., 
Tinct. aurant. cort., 
Aquaa destil., 



gr. ss-y 

3ss; 

3'j-5j ; 

, Si. 



Sig. One-half ounce t. i. d. after meals, 
vel 



2 

8-32 

48 

4 

ad 100 

(Keyes.) 



03-.13 



R. Hydrarg. bichlor. 
Hydrarg. biniod., 
Potass, iodid., 
Inf. gent. co. vel 
Syr. sarsaparillae co.. 



gr- J-iJ 

3HJ ; 

ad §iv; 



4-8 
ad 128 



06-.13 



M. 



Sig. One drachm t. i. d. after meals. 
These three are used in syphilis. 

3. R. Pil. hydrarg., gr. xl ; 2166 

Ferri sulphat. exsic, gr. xx ; 1 33 

Ext. opii, gr. v ; 133 M. 

Div. in pil. No. xl. 
Sig. One t. i. d. (Taylor.) 
Used in syphilis. Sulphate of quinine may be substituted for the iron. 



4. R. 01. gurjun., £j; 

Liquor calcis, ^iij ; 

Sig. One-half ounce twice a day. 
Used in leprosy. 

5. R. Tinct. cannabis indicae, tT\,x-xxx : 

Pulv. tragacanth. co., gr. x ; 

Aquae destil., ad §j ; 

Used in pruritus and prurigo. (Bulkley.) 

6. Startin's Mixture : 



33)33 
100 M. 



0.66-2 
ad 32 



R. Magnesii sulphat., 5 v j _x y ', 20-30 

Ferri sulphat., 3J ; 3 

Acid, sulphur, dil., gij ; 6 

Syr. pruni virgin., ^j > 24 

Aquae destil., ad giv; ad 100 

Sig. One drachm t. i. d. after meals, through a tube, 
tive and tonic. 



M. 

As a lax* 



gr. xxij ; 


1 


gr. xxx ; 


2 


q. s.; 


q. s. 



75 



50- 



7. Asiatic Pills: 

R. Acid, arsenosi, gr. xj ; 

Pulv. pip. nigra, . 3;iss : 

Gummi acacias, 
Pulv. althse rad., 

Aquae destil., q. s. ; q. s. M. 

Div. in pil. No. c. 

Sig. One to three pills a day after meals, and increase to tolerance. 
Used in psoriasis. 



is 


APPENDIX. 


8. 


R. Hvdrarg. clilor. mitis 

Ferri lactatis, 

Sacch. alb., 
Ft. in pulv. No. x. 




gr. jss ; 
gr. iij 5 
gr. xv ; 




Sig. One to four daily. 


Mont 


•) 


Us 


ed in infantile syphilis. 







1096 
192 
1 M. 



C. FOR EXTERNAL USE. 

a. Caustics. 
1. Cosine' s Paste: 

R. Acid, arsenosi, gr. x ; |( 

Hvdrarg. sulphuret. rub., ^ss; 21 

Ungt. rosre vel \ - . 

Sacch. alb., / 5S& ' 

To destroy epithelioma or other new growths. 



16 



2. Marsden's Paste: 

R. Pulv. acid, arsenosi, 2 parts by weight. 

Pulv. gummi acaciee, 1 part " " 

Mix with a twenty per cent, solution of cocaine to form a paste 
just before using, and apply to not more than one square 
inch at a time. 
Same indications as Cosine's Paste. 

3. Bougard's Paste: 

R. Wheat flour, \ .. __ 

Starch, } aa 60 parts. 

Arsenic, 1 part. 

Cinnabar. "I ... 

Sal ammoniac. } aa 5 l iarts - 

Corrosive sublimate, I part. 

Sol. chlor. of zinc @ 52°, 24o parts. M. 

Grind first six ingredients to a fine powder, then mix them in a 
mortar. Add solution of zinc chloride slowly stirring. Keep 
in earthen jar. May add cocaine up to 20 per cent, to allay 
pain. 
Sig. Apply accurately to part; keep on for thirty hours; follow 
with poultice. 

4. Depilatory Paste: 

R. Barii sulphid., ^ij ; 81 

Zinci oxidi, "I -- ... ,J 

Amyli, J aa S"J; 12 ! M. 

Make into a paste with water and apply a thin coating for ten to 
fifteen minutes, then clean off and apply a bland ointment. 



APPENDIX. 



619 



5. Salicylic Acid (Crocker) : 

R. Glycerini, 3J ; 

Acid, salicyl., q. s. ; 

Make in consistency of thick cream, 
application may add 



32i 



To 



M. 

painfulness of 



R. Ac. carbolici vel 
Creosoti, 



} *i; 4 i 

Used to destroy warts, lupus, and epidermic thickenings 



6. Vienna Paste: 

R. Calcis, \ 

Potash, } aa P- ! 

Make into a paste with alcohol just before using. 
Used in lupus and scrofulides. 



7. Canquoin's Paste : 




R. Zinci chlor., \ 
Amnion, chlor., J 


aa 3j; aa 4 


Pulv. amyli, 
Aqua? destil., 


3 jss; (3 
q. s. ; q. s. 


Make into a paste at time of using. 


Used to destroy lupus, epithe' 


ioma, and the like. 


8. Middlesex Hospital Paste : 




R. Zinci chlor., "1 
Liq. opii sed., / 
Amyli, 
Aquse destil., 


aa ^iv ; aa 8 

.%'; 32 


Same indications as Canquoin's paste. 


9. R. Zinci nitrat., 


1 part. 


Mica? panis, 


2 parts. 


Mix before using. 




b. 


Lotions. 


1. Belladonna Lotion: 




R. Tinct. belladon., \ 
Glycerini, / 
Aquse destil., 


aa 1 part, 
8 parts. 


For erysipelas. (Piffard.) 




2. Bismuth Lotion: 




R. Bismuth, subnitrat., 


gr. vijss ; 


Zinci oxidi, 


,^ss ; 2 


Glycerini,. 
Hydrarg. bichlor., 
Aquse rosse, 


ll\,xv ; 1 

a ; 32 



M. 



016 



For rosacea and hypersemic conditions. 



620 



APPENDIX. 



3. Calamine Liniment: 

R. Pulv. calamin., 
Zinci oxidi, 
Linimenti calcis. 



jr. xl : 



For erythema, eczema, and hypereemic conditions. 



4. Calamine Lotion : 



2 66 
2 
32 M. 



; . Pulv. calamin., 


gr. xx ; 


21 


Zinci oxidi, 


^ss; 


3 


Glycerini, 


5»; 


20 


Aq. calcis, 


•?vj ; 


36 


Aq. rosae, 


ad 51V: 


ad 200 



For erythema and eczema. (Bulkley.) 



5. Carbolic Acid Lotion: 

R. Acid, carbol., 
Alcoholis, \ 
Aquae destil., f 

For erysipelas. (White.) 



3j; 

Oss 



4 

aa. 250 



6. Carron Oil 

R. Aq. calci 
01. ol' 
01. lin 

For burns, 



calcis, I 
ilivse vel > 
ini, J 



Fqual parts. 



7. Coster* Paint. 

R. Iodini, 
Ol. picis 



i«juidae, 



8. Fox's C. C C. Mixture . 

R. Chrysarobin., "I 

Ol. cadini, j 
Acid, carbol ici, 
Acid, oleici, 
For psoriasis. 



SHJ ; 4-81 

l\ ; 30 M. 



aa 2 parts. 

1 part. 
50 parts. M. 



9. Hardawcu/s Lotion for Lichen Planus. 



:. Sapo. oliva? prcep., 


5 iv ; 


100 




Ol. rusci, "i 
Glycerini, j 


aa jg; 


aa 25 




Ol. rosniarini, 


jtiwj 


4 




Alcoholis, 


ad =vii.j; 


ad 200 


M. 



APPENDIX. 



621 



10. Kaposi's Tar Lotion: 

R. 01. rusci, 

iEtheris sulphuris, 
Alcohol is, 
Filtra et adde 

01. lavandula;, 
Used in psoriasis. 

11. Kummerf eld's Lotion : 

R. Spts. camphorae, ) 
Spts. lavandulae. / 
Sulph. praecip., 
Aq. cologniensis. 
Aquae destil., 
For cosmetique. 

12. Liquor Picis Alkalinus : 

R. Picis liquidse, 

Potass, causticae, 
Aquae destil., 



50 parts. 



aa 75 



aa £ss; 
gr. x^ 

S'j; 



3v; 



M. 



M. 



Dissolve the potassa in the water and add slowly the tar in a 
mortar with friction. 
For chronic eczema, or, diluted ten to twenty times, for acute eczema. 

13. Lotio Alba : 

R. Potassae sulphurat., ) 



Zinci sulphat. 
Aquae rosae, 
For acne and rosacea. 



aa 3j; 
ad Jiv; 



aa 4 

ad 128| 



14. Lotio Ac. Boracis: 

R. Ac. boracis, sjiv vel q. s. ; 16| 

iEtheris sulph. methyl.,' % v. ; 1601 

Spts. vini rect., ad gxx . a( \ q^q\ jyj 

For ringworm, after washing with hot water and soap, and drying. 
(A. Smith.) 

15. Lotio Plumbi et Opii: 

R. Liq. plumbi subacetat. dil., \ -- -., 

Tinct. opii, J ™' 

Aquae destil., ad Oj ; 
For acute inflammatory conditions. 



aa 32 
ad 500' 



16. R. Naphtoli, 

Spts. sapo. viridis, 

Alcoholis, 

Bals. peruv., 

Sulph. loti, 
For sycosis. (Kaposi.) 



gr. xv ; 
3vj ; 

gtt. XXX 



M. 



M. 



622 



APPENDIX. 



17. R. Amyli glycerolis, ) 
Ol. cadini, j 

Sm[jo viridis, 

For psoriasis. External use. 



aa 100 parts. 



18. Piffard's Substitute for Tar . 

R. Ac. salityl., 
01. lavandulse, 
01. citronellae, 
Ol. pini sylvestris, 
01. ricini, 

tor eczema capitis. 

19. R. Sodii hypophosphitis, 

Glycerini, 
Aquae destil., 

For dermatitis venenata. (Morrow.) 

20. Sulphur Lotion: 

R. Sulphuris loti, | 
Alcoholis, 
jEtheris, 

(ilycerini, 
Potass, carl)., J 
Aq. rosse, 

Used in acne. 



gr. x-xxx; 


0.66-21 


3yss; 


10 


gss; 


2 


!>j; 


64 


sj>- ; 


m 


fj; 


30 


Sviij; 


15 


250i 



aa 3 ij ; aa 



5vij; 2501 M. 



21. Thymol Lotion: 

R.' Thymol., 1 

Eiq. potassa?, J 
Glycerini, 
Aq. sambnci, 

For seborrho?a sicca capiti 
the amount of thvmol. 



:>a a 



aa 4 

15 
250 



M. 



Also for pruritus cutaneus, with double 



22. Tinctura Saponin Viridis 

R. Sapo. viridis, 1 
Alcoholis, { 



Equal parts. 



M. 



23. Tinrt. Saponis Co. of Hebra : 

R. Ol. cadini, ] 

Sapo. viridis, >■ 
Alcoholis, J 

Filtra et adde 

Spts. lavandnlse, 
Stimulant in chronic eczema. 



aa 5J 



3y 



?,2 



M. 



APPENDIX. 



623 



24. Vleminckx's Solution : 

R. Calcis vivae, giv; 161 

Sulphur, sublimat., %j ; 32 

Aq. destil., gx ; 3201 M. 

Boil together with constant stirring until the mixture measures 
six fluid ounces, then filter. 
Useful in scabies, psoriasis, and acne. 

25. R. Zinci oxidi, giv ; 161 

Ac. carbol., 3,j ; 4 

Aquae calcis, Oj ; 5001 M. 

For dermatitis venenata. (White. ) 



1. Bassorin Paste. 

R. Bassorin, 
Dextrin, 
Glycerin, 
Water, 



Ointments. 



48 parts. 
25 " 
10 " 
100 " 



M. 



Gelatin Paste (Unna) : 

R. Zinci oxidi, 30 parts. 

Gelatini, 30 " 

Glycerini, 39 " 

Aquae destil., 10 " M. 

Heat in water bath before using. 
a prc J active dressing and excipient. 



3. Bismuth Ointment: 

R. Bismuthi subnit., 
Kaolini, 
Vaselini, 

For chloasma. (Unna.) 

4. R. Ac. borici, 

Ac. salicylici, 
Ungt. aqua? rosse, 



aa 3jss ; 

£vj ad |jsp ; 



gr. x ; 

gr. xv ; 



For chromidi 



(Van Harlingen.) 



7:5 



5. Chrysarobin Ointment: 
R. Chrysarobin., 
Ac. salicylici, 
Plasment. veJ \ 
Adipis, J 

Used in psoi-iasis and ringworm. 



gr. 1; 


3 


gr. x; 




3j; 


30 



M. 



624 



6. R. C'lnvsarobin., \ 
Icl.thyol., / 
Ac. salicyl., 
Ungt. simpl., 

Used in leprosy. (Unna. ) 



APPENDIX. 

aa gr. lxxv 
gr. xxx ; 



7. Diachylon Ointment (Hebra) : 

R. 01. olivae, Sjxv ; 

Plumbi oxidi, Jjiij %x] 

Boil together to a good consistence and add 



100 



480' 

120I 



01. lavandulae, 


3u; 


81 


8 R. Hvdrarg. aniinon., 1 
Bismuthi subnit., / 
Ungt. aq. rosw, 

Used in lentigo. (Hardaway.) 


aa 3J; 

5.1; 


aa 4 
80] 


9. R. Hvdrarg. amnion., 

Hvdrarg. chlor. mitis, 
Vaselini, 


gr. xx-xl ; 
gr. xl-lxxx 

.3; 


5-101 

; 10-20 

100 


Used in seborrhoea sicca capitis and pityriasis 


capitis. 


10. R. Hvdrarg. bichlor., 
Ac. carbol., 
Ungt. zinci oxidi, 


gr. j-v ; 
gr. xx ; 

Si ; 


0.2-1 

4 

100 



M. 



Used in lichen ruber. (Unna.) 

11. R. Ac. salicylici, 

Ungt. hvdrarg. ox. rub 
Ungt. aquae rosse, 

For blepharitis. (Webster.) 

12. R. Hydrarg. protiodid., 

Hvdrarg. amnion., 
Ungt. simpl icis, 
Used in acne. (Duhring.) 

13. R. Ungt. Ian*, 

Ac. acetici, 
Adepis benzoat., 
Sulph. praecip., 

Used in acne. (Unna.) 

14. R . Hvdrarg. sulph. rubri, 

Sulph. sublimat., 
Adipis, 
01. bergamot., 
Used in sycosis. (Behrend.) 



••> 33 ; 

3 V J ; 




4 
24 


gr. v~xv ; 


0.33-11 


gr. x-xxx 

.?j; 


0.0 


32 


Sliss ; 

gij gr. xlv; 

gr. xlv; 




10 

1] 

10 

3 


gr. xv ; 
aa 5HJ ; 


ad 


75 


q. s.; 


q. s. 



M. 



M. 



APPENDIX. 



625 



15. R. Ungt. diachyli (Hebra), \ 
Ungt. zinci oxidi, J 

Ungt. hydrarg. amnion., 
Bismuthi subnitrat., 

For sycosis. (Robinson.) 



16. 



Lassar's Paste : 
R. Zinci. oxidi, 
Aniyli, 
Vaselini, 



aa 5jss : 
3J*» ; 



aa 3ij ; 
ad ^iv 



aa 50 

10 
5 



ad 32 



M. 



As a protective application and as an excipient for otber drugs. 



17. 



R. Zinci oxidi, 
Creta prseparat., 
Liquor plumbi, 
01. lini, 



Mix tlie first two togethei 
part to the other. 
Use as a protective in eczema. 

18. Nuphtol Ointment: 
R. /3-naphtol., 

Creta prseparat., 
Sapo. viridis, 
Adipis, 
Used in scabies. (Kaposi.) 

19. Naphtol Ointment : 
R. /?-naphtol., 

Sulph. prsecip., 
Vaselini, "I 

Sapo. viridis, J 
Used in acne. (Lassar.) 

20. R. Ac. salicylici, 

Sulphur, praecip., 
Lanolini, 
Vaselini, 
For chromophytosis. (Brocq.) 

21. R. Sulphur., 

Potass, carb., 
Adip. benzoat., 
01. chamomilis, 
Used in scabies. (Wilson.) 

22. Helmerich's Ointment: 
R. Sulphur., 

Potass, carb., 
Adipis, 
Used in scabies. 



40 parts, 
aa 20 " 
and the last two together, and add one 
(Unna.) 



giij gr. xl ; 



adgi 



10 parts. 
50 " 



aa 25 



2-3 parte 
10-15 " 
70 " 
18 " 



M. 



M. 



3ss 



32 



160 

2 



|y; 


30i 




15 


o vii J '• 


250| 



^M. 



626 



APPENDIX. 



23. Wilkinson's Ointment (Hebra) : 
R. Sulphuris, { 

01. cadini, a 



a a 16! 



oajju. vinuis, ! 

Adipis, / 


aa 5J; 


aa 32 






Creta prseparat., 


3'jss ; 


10 


M. 


Used in scabies. 








24. R. 01. fagi, 1 
Flor. sulph., J 








aa sjijss; 


aa, 10 






Pulv. cretse alb., 


Si; 


4 






Adipis, 1 
Sapo. viridis, J 


aa 3v; 


aa 20 




M. 


For sycosis. (H. Hebra.) 








25. R. 01. cadini, 1 
Zinci oxidi, J 








aa 3ss-j ; 


aa 2-4 




Ungt. accuse rosae, 


o.i; 


30 


M. 


For chronic eczema. 








26. R. Zinci oxidi, "1 
Zinci carbonat., J 




aa 4 




aa 3J ; 




Ungt. aq. rosae, 


ad 5J ; 


ad 32| 


M. 


For sycosis after shaving, (T. 


Fox.) 






27. R. Terrae siliceae, 


gr. xx ; 


1133 




Zinci oxidi, 


3ij ; 


8 




Adipis benzoat., 


ad^j; 


ad 32! 
(Unna.) 




28. R. Terrse siliceae 


3ss; 


2 






Sulphur, praecipitat., 


3g ; 


8 






Zinci oxidi, 


3iss ; 


6 






Adipis benzoat, 


adgj; 


ad 32 










(Unna.) 




d. Miscellaneous. 






1. Anti-pruritic Powder : 








R. Camphori, 


gss; 


3 ! 




Zinci oxidi, 


3u; 


15 




Amyli, 


3iv; 


30 


M. 






(Bulkley.) 


2. Corn Remedy: 








R. Ac. salicylici, 


gr. xv ; 


11 




Ex. cannabis indicap, 


gr. viij ; 


5 




Alcoholis, 


"ixv; 


ll 




^Etheris, 


TlLxl; 


266 




Collodion flex., 


Tr^lxxv ; 


5 


M. 


Apply with brush three times a day for 


i week. Soak feet and 


pick out corn. (Vigier.) 









APPENDIX. 627 

3. Epilaling Stick: 

R. Cerae flavre, ^iij ; 12 

Laccse in tabu lis, ^iv ; 16 

Picis burgundica?, gx ; 40 

Gummi damar., ^jss ; 48 M. 

Make in stick one-half to one inch in diameter and two inches 
long. (Bulkley.) 

4. Glycerin Jelly : 

R. Gelatini, gr. xxv; 1(66 

Glycerini, gr. ccxxv ; 15 

Aquae destil., 3iv ; 16) M. 

5. Glycerole of Subacetate of Lead : 

R. Plnmbi acetat., gr. cxx ; 81 

Plumbi oxidi, gr. lxxxiv ; 6 

Glycerini, | j ; 32| M. 

Digest the lead in the glycerin heated to 300° F. in an oil bath 
for half an hour, constantly stirring. Filter in a chamber 
heated to 300° F. 
Dilute from three to seven times with water and glycerin, and 
use as astringent and sedative in chronic eczema. (Squire.) 

6. Unna's Superoxide of Soda Soap : 

R . Superoxide of soda, 5 to 20 per cent, in 

Liquid paraffin, 30 parts, 

Fully dried-out soap, 70 " 



INDEX 



ABSCESS, 61 
Acanthosis bullosa, 233 
Acanthosis nigricans, 62 
Acarus scabiei, 491 
Achorion Schoenleinii, 271 
A chroma, 348 
Acid, oleic, 46 

oxynaphthoic, 50 
Acne, 63 

diagnosis, 69 
etiology, 65 
pathology, 68 
prognosis, 78 
treatment, 71 

adenoid, 371 

albida, 383 

arthritique, 80 

artificialis, 78 

atrophica, 78 

bromic, 167 

cachecticorum, 78 

cornea, 468 

erythematosa, 477 

fluente", 507 

follicularis, 138 

frontalis, 80 

indurata, 65 

iodic, 169 

keloid, 171 

keratosa. 79 

lupoid, 80 

mentagra, 516 

miliare scrofuleuse, 80 

necrotica, 80 

papulosa, 63 

pilaris, 80 

punctata, 63, 138 

punctuee, 138 

pustulosa, 63 

rodens, 80 



rosee, 477 
scrofulosorum, 78 



Acne sebacea, 507 
sebacee, 507 

cornee, 331, 468 
simplex, 63 
sycosis, 516 
syphilitica, 537 
tar, 78 

ulcereuse, 80 
urticata, 81 
varioliformis, 80, 385 
vulgaris, 63 
Acrochordon, 82, 280 
Acrodynia, 82 
Acromegaly, 82 
Actinomycosis, 82 
Addison's keloid, 501 
Adeno-carcinoma, 83 
Adenoma, 83 
Adenotricliie, 516 
Adeps lanpe, 46 
Agnine, 46 
Ainlmm, 84 
Airol, 47 
Albinism, 348 

Aleppo boil, bouton, or evil, 84 
Algidite progressive, 497 
Alopecia, 85 
adnata, 85 
areata, 94 

diagnosis, 99 
etiology, 96 
pathology, 98 
prognosis, 102 
treatment, 99 
circumscripta, 94 
follicularis, 94 
furfuracea, 90 
pityrodes, 90 
prematura idiopathic^, 86 
etiology, 87 
treatment, 87 
symptomatica, 90 
senilis, 86 



630 



INDEX. 



Alopecia syphilitica, 92 

Alopecie cicatricielle innominee, 

282 
Alphos, 453 
Altlial, 46 
Alumnol, 47 
Anaesthesia, 102 
Anatomical tubercle, 538 
Angiokeratoma, 102 
Angioma, 396 

cavernosum, 396 

pigmentosum et atrophicum, 
110 

serpiginosum, 104 
Angiomyoma, o92 
Anhidrosis, 104 
Anonychia, 105 
Anthrarobin, 47 
Anthrax, 122, 473 
Area celsi, 94 

occidentalis diffluens, 94 
Argyria, 105 
Aristol, 47 

Arrectores pilorum, 27 
Asiatic pills, 017 
Atheroma, 506 
Atrophia cutis, 109 

pilorum propria, 

unguium, 109 
Atrophoderma, 109 

albidum, 112 

idiopathica diffusa, 113 

pigmentosum, 110 

senilis, 114 

striatum et macula turn, 114 
Aussatz, 340 

BACILLUS acnes, 68 
Bad disorder, 526 
Baelzer's disease, 115 
Baker's itch, 213 
Baldness, 85 

circumscribed, 94 
Barbadoes leg, 226 

glandular disease of, 226 
Barbers' itch, 516, 576 
Bartfinne, 516 

parasitische, 575 
Bartnechte, 516 
Bassorin, 46 
Baths, 615 
Bedbug, 410 



Birth mark, 396 
Blackheads, 138 
Blasenausschlag, 419 
Blutfleckenkrankheit, 468 
Blutschwiir, 286 
Boil, 286 

Bougard's paste, 618 
Bouton, 63 
Brand rose, 116 
Brandschwiir, 122 
Bricklayers' itch, 213 
Bromic acne, 167 
Bromidrosis, 116 
Bucnemia tropica, 226 
Bulla, the, 31 
Bulpiss, 117 
Bunion, 118 
Burning, 42 
Burns, 147 

CACOTROPHIA folliculorum, 
334, 468 
Calculi, cutaneous, 384 
Callositas, 118, 333 
Callus, 118 
Calotte, the, 274 
Calvezza, 85 
Calvities, 85 
Cancer, chimney-sweeps', 236 

en cuirasse, 126 

epithelial, 234 

skin, 234 

spider, 567 

tnbereux, 327 
Cancroide, 234 
Canites, 119 
Canquoin's paste, 619 
Carate, 121, 430 
Carbuncle, 122 
Carcinoma, 125 

lenticulare, 125 

melanodes, 126 

tuberosum, 126 
Carron oil, 620 
Chalazion, 384 
Chalazodermia, 178 
Chaleur du foie, 127 
Chancre, 526 
Chap, 126 
Charbon, 473 
Cheilitis glandularis, 127 
Cheiro-pompholyx, 439 



INDEX. 



631 



Chelis or cheloide, 327 
Chicken-pox, 601 
Chigoe, 410 
Chilblain, 149 
Chloasma, 127, 132 

uterinum, 128 
Chorionitis, 498 
Chromidrosis, 130 
Chromophytosis, 132 
Cicatrix, the, 33 
Cimex lectularius, 410 
Claret stain, 396 
Classification, 51 
Clastothrix, 106 
Clavus, 136 

syphiliticus, 137 
Clou, 286 
Cnidosis, 594 
Cochin-China leg, 226 
Cold sore, 295 
Collodion, 44 

Colloid degeneration of the skin, 
138 

milium, 138 
Color in diagnosis, 41 
Columnse adiposae, 21 
Comedo, 138 
Condyloma acuminata, 603 

lata, 534 
Congelatio, 149 

Connective tissue, subcutaneous, 21 
Cor, 136 
Corium, 20 
Corn, 136 

Corne de la peau, 142 
Cornu cntaneum, 142 

humanum, 142 
Corpuscles of Krause, 22 

of Meissner, 22 
Cosme's paste, 618 
Coster's paint, 620 
Couperose, 477 
Craw-craw, 143 
Creolin, 48 
Crust, the, 32 
Crusta lactea, 206 
Cute, 430 
Cutis anserina, 143 

pendula, 178 

tensa chronica, 498 
Cyanopathie cutanea 130 
Cyst, dermoid, 507 



Cyst, sebaceous, 506 
Cysticercus cellulosa; cutis, 144 

DACTYLITIS, 553 
Dandruff; 437, 509 
Dartre erythemo'i'de, 249 
humide, 182 

pustuleuse mentagre, 516 
rongeante, 371 
vive, 182 
Dartrous diathesis, 144 
Dasyma, 307 

Defluvium capillorum, 93 
Demodex folliculorum, 141 
Dermalgie, 145 
Dermatalgia, 145 
Dermatitis ambustionis, 147 
blastomycotica, 146 
bullosa, 233 
calorica, 147 
congelatioriis, 149 
con tusi forme, 259 
epidemica, 150 
erythematosa, 249 
exfoliativa, 151 

diagnosis, 163 
etiology, 162 
pathology, 162 
treatment, 164 
neonatorum, 155 
fungoid, 390 
gangrenosa, 156 

infantum, 157 
glandularis erythematosa, 36? 
herpetiformis, 159 

diagnosis, 154 
etiology, 153 
pathology, 153 
treatment, 154 
malignant papillary, 404 
medicamentosa, 165 
papillaris capillitii, 170 
papillomatosa capillitii, 170 
psoriasiformis nodularis, 431 
repens, 172 
seborrhoica, 221 
traumatica, 173 
venenata, 174 
z-ray, 172 
Dermatol, 48 
Dermatolysis, 178 
Derm atomy cosis favosa, 266 



632 



INDEX. 



Dermatomycosis microsporina, 132 


Eczema seborrhoicum, etiology, 223 


tonsurans, 571 


pathology, li24 


Derinato-sclerosis, 498 


treatment, 225 


Dermatosis Kaposi, 110 


squamosum, 186 


Desmoids, 280 


tuberosum, 390 


Diabetic eruptions, 178 


unguium, 216 


Diachylon ointment, 024 


universale, 217 


Diagnosis, 27 


verrucosum, 187 


Diaskop, 43 


vesiculosum, 185 


Distichiasis, 179 


Eigon, 48 


Don'ts, 57 


Eiterpusteln, 180 


Dracontiasis, 293 


Ekzein, 182 


Durillon, 118 


Elastic webbing, 46 


Dysidrosis, 439 


Elephantiasis, 226 




diagnosis, 230 


T7CDERMOPTOSIS, 385 
Li Ecphyma globulus, 179 


etiology, 229 


pathology, 230 


Ecthyma, 180 


prognosis, 231 


infantile gangreneux, 158 


treatment, 230 


terebrant del'enfance, 158 


arabum, 226 


Eczema, 182 


Indica, 226 


diagnosis, 189 


Grsecorum, 340 


etiology, 187 


Emol, 48 


pathology, 189 


Emphysema. 231 


prognosis, 204 


Endothelioma, 231 


treatment, 193 


Endurcissement alhrepsique, 497 


ani, 204 


Ephelides, 338 


aurium, 205 


Ephidrosis, 304 


barbae, 206 


cruenta, 394 


capitis, 206 


tincta, 130 


crurum, 209 


Epidermis, 17 


erythematosum, 184 


Epidermolysis, 233 


exfoliativum, 151 


Epilating stick, 627 


foliaceum, 151 


Epithelialkrebs, 234 


genitalium, 209 


Epithelioma, 234 


hvpertrophicum, 390 


diagnosis, 237 


infantile, 218 


etiology, 236 


intertrigo, 2 1 1 


pathology, 237 


labiorum, 211 


prognosis, 241 


madidans, 185 


treatment, 238 


mammarum, 211 


adenoides cystictim, 242 


mammillarum, 211 


contagiosum, 385 


manuum, 213 


multiple benign cystic, 242 


marginatum, 569 


Epitheliomatose, eczematoide de la 


narium, 215 


mamelle, 404 


palpebrarum, 215 


pigmentaire, 110 


papulosum, 185 


Equinia, 242 


pedum, 216 


Erbgrind, 266 


pustulosum, 186 


Eruption, recurrent summer, 302 


rubrum, 185 


Eruptions, color of, 41 


seborrhoicum, 221, 507 


configuration of, 35 


diagnosis, 224 


feigned, 277 



INDEX. 



633 



Eruptions, location of, 34 

ringed, 35 
Erysipelas, 243 

diagnosis, 246 
etiology, 245 
prognosis, 248 
treatment, 248 

suffusum, 249 
Erysipeloid, 248 
Erythema, 249 

annulare, 256 

bullosum, 257 

caloricum, 250 

circinatum, 256 

elevatum diutinum, 262 

exudativum, 255 
diagnosis, 261 
etiology, 260 
pathology, 261 
prognosis, 262 
treatment, 261 

fugax, 252 

gangrenosum, 263 

gyratum, 257 

hypersemicum, 249 

induratum, 263 

intertrigo, 250 

iris, 257, 258 

lseve, 252 

marginatum, 257 

multiforme, 256 

neonatorum, 253 

nodosum, 259 

papulatum, 256 

paratrimma, 252 

pernio, 149, 250 

roseola, 252 

scarlatiniforme, 254 

simplex, 250 

traumaticum, 250 

tuberculatum, 256 

urticans, 252 

vesiculosum, 257 
Erytheme centrifuge, 365 

indure des scrofuleux, 263 

noueux, 259 

papuleux desquamatif, 432 
Erythrasma, 264 
Erythrodermie exfoliante, 151 

pityriasique en plaques dis- 
seminees, 265 
Erythromelalgia, 266 



Esthiomene, 260, 371 
Europhene, 48 
Excoriation, the, 32 



FAECY, 242 
Favus, 266 _ 

diagnosis, 272 
etiology, 271 
pathology, 271 
prognosis, 277 
treatment, 274 
Feu sacre, 243 
Fenergiirtel, 611 
Feuermal, 396 
Fever blister, 295 
Fibroma, 278 

fungoi'des, 390 

lipomatodes, 605 

molluscum, 278 

pendulum, 280 
Fibromyoma, 392 
Fikosis, 516 
Filaria sanguinis hominis, 229 

medinensis, 293 
Filmogen, 48 
Finnen, 63 

Fischschuppenausschlag, 315 
Fish-skin disease, 315 
Fissure, 33 
Flea-bites, 281 
Flechte, fressende, 371 

kleien, 132 

niissende, 182 

scheerende, 569, 572 
Fleckenmal, 393 
Fleshworms, 138 
Fluxus sebaceus, 507 
Folliculitis, 281 

barbae, 516 

decalvans, 282 

pilorum, 516 
Foot, tubercular disease of, 285 
Fordyce's disease, 284 
Fragilitas crinium, 105 
Frambcesia, 170, 610 
Freckles, 338 
Frieselausschlag, 381 
Frost-bite, 149 
Fuchsine, 48 

Fungous foot of India, 285 
Furoncles atoniques, 180 



634 



INDEX. 



Furunculi atoniei, 180 
Furunculus, 286 

GALE, 488 
Gallacetophenone, 49 
Gangrene, symmetrical, 157 
Gangrenes multiples cacheetiques, 

158 
Gefassmal, 396 
Gelanthum, 46 
Gelatin preparations, 45 
Geromorphisme cutane, 291 
Glanders, 242 
Glossy skin, 113 
Glycerin jelly, 627 
Glvcerole of subacetate of lead, 

627 
Gneis, 507 

Gommes scrofuleuses, 504 
Goose-flesh, 143 
Granuloma. 292 
fungoi'des, 390 
necrotics., 292 
tropicum, 610 
Grayness of hair, 119 
Grubs, 138 
Grutum, 383 

Guinea-worm disease, 293 
Gumma, scrofulous, 504 

syphilitic 543 
Gfirtelkrankheit, 611 
Gutta rosacea, sen rosea, 476 

HJCMATIDROSIS, 294 
Haemidrosis, 294 
Hfemorrhcea petechialis, 46S 
Hair, anatomy of, 23 

blanching of, 119 

discolorations of. 294 

ringed, 120 

superfluous, 307 
Hand-and foot disease, 426 
Harlequin foetus, 317 
Harvest hug, 409 
Hauthorn, 142 
Hautrose. 24:; 
Hautrothe, 249 
Hautschmerz, 145 
Hautsclereme, 498 
llautwiirmer, 138 
Heat eruption, 182 
Helmerich's ointment, 625 



Hemiatrophia facialis progressiva, 

113 
Hernia carnosa, 226 
Herpes circinatus, 159, 569, 571 
bullosas, 299 

circine parasitaire, 572 

esthiomenes, 371 

facialis, 295 

febrilis, 295 

gestationis, 159, 300 

iris, 258 

lahialis, 295 

phlyctsenoides, 159 

praepuiialis. 297 

progenitalis, 297 

pustulosus nientagra, 516 

squamosus, 571 

tonsurans, 571 
barba>, 575 
maculosus, 432 

tonsurante, 572 

zoster, till 
Herpetide, 300 

exfoliative, 151 
Hide-bound disease, 498 
Hidrocystoma, 300 
Hirsuties, 307 
History of case, 41 
Hitzbllitterchen, 182 
Hives, 594 _ 
Homines pilosi, ^07 
Horn, cutaneous, 142 
Hiihnerauge, 136 
Hutchinson's teeth, 552 
Hyalomder Haut, 138 
Hyalome cutane, 138 
Hydradenitis, 287 
Hvdradenomes eruptifs, 242 
HVdroa, 159, 302 

bulleux, 160 

febrilis, 295 

herpetiforme, 160 

puerorum, 302 

vacciniforme, 302 

vesieuleux, 259 
Hydroxylamine, 49 
Hypera?sthesia, 303 
Hyperalgesia, 303 
Hyperidrosis, 304 

oleosa, 511 
Hyperkeratosis atrophica follicu- 
laris, 441 



INDEX. 



635 



Hyperkeratosis excentrica, 441 
Hypertrichosis, 307 

etiology, 310 

treatment, 312 

TCHTHALBIN, 49 

1 Ichthyol, 49 

Ichthyose anserine des scrofuleux, 

334 
Ichthyosis, 315 

congenita, 317 

follicularis, 331, 334, 468 

hystrix, 317, 407 

intrauterina, 317 

linguae, 351 

palmaris et plantaris, 333 

sebacea, 507 
cornea, 468 
Idrosis, 304 
Ignis sacer, 611 
Impetigo, 319 

contagiosa, 320 
diagnosis, 323 
etiology, 322 
pathology, 323 
prognosis, 326 
treatment, 326 

herpetiformis, 326 

of Bockhardt, 320 

parasitica, 320 

simplex, 319 
Induratio telae cellulosse, 497 
Inflammatory fungoid neoplasm, 

390 
Initial lesion of syphilis, 526 
Intertrigo, 250 
Iodic acne, 169 
Iodolen, 49 
Ionthus, 63 
Itch, 488 

barber's, 516, 575 

bricklayers', 213 

grocers', 213 

prairie, 443 

washerwoman's, 213 

JIGGER, 410 
Juckblattern, 443 

KAHLHEIT, 85 
kreisfleckige, 94 
Kelis, 327 



Keloid, 327 

of Addison, 501 

of Alibert, 327 
Keratolysis exfoliativa, 331 
Keratoma, 118 

follicularis, 317, 331 

palmare et plantare heredi- 
tarium, 333 
Keratosis diffusa, 317 

epidermica, 317 

follicularis, 331, 468 

intrauterina, 317 

palmaris et plantaris, 333 

pilaris, 334 
Kerion, 336, 573 

Celsi, 336 
Kleienfiechte, 132 
Knollenkrebs, 327 
Koltun, 438 
Kriitze, 488 
Kraurosis vulva?, 337 
Krause's corpuscles, 22 
Kummerf eld's lotion, 621 
Kupferfinne, 477 
Kupferrose, 477 
Kupfrigesgesicht, 477 

LANOLIN, 46 
Lassar's paste, 625 
Leberflecken, 127 
Leichdorn, 136 
Lentigo, 338 

maligna, 110 
Leontiasis, 340 
Lepothrix, 339 
Lepra, 340, 453 
alphos, 453 
arabum, 340 
Leprosy, 340 

diagnosis, 346 
etiology, 345 
pathology, 345 
prognosis, 346 
treatment, 346 
Lombardian, 417 
Leptus autumnalis, 409 
Leucasmus, 348 
Leucoderma, 348 
Leucokeratosis buccalis, 351 
Leuconychia, 351 
Leucopathia, 348 
unguium, 351 



636 



INDEX. 



Leucoplakia, 351 
Lichen annularis. 352 

circinatus, 507, 509 

hypertrophicus, 357 

menti, 516 

obtnsus, 357 

pilaris, 334, 353 

planus, 353 

ruber acuminatum, 359 
moniliformis, 357 

scrofulosorum, 362 

scrofulosus, 362 

simplex, 185 

spinulosum, 468 

tropicus, 382 

verrucosus, 357 
Linese albicantes, 115 
Linsenflecke, 338 
Linsenmal, 393 
Liodermia essentialis cum melan- 

osi, etc., 110 
Lipoma, 364 
Liquor anthracis, 50 

gutta perchse, 44 

picis alkalinus, 621 
Liver spot, 127 
Lotio alba, 621 

plumbi et opii, 621 
Lousiness, 411 
Lues, 525 
Lupoid acne, 80 
Lupus ervthematodes, 365 

erythematosus, 365 
diagnosis, 368 
etiology, 367 
pathology, 367 
prognosis, 370 
treatment, 369 

exedens, 371 

exfoliativus, 371 

exulcerans, 372 

hypertrophicus, 373 

lymphaticus, 379 

miliaris, 80 

papillaire verruquex, 588 

papillomatosis, 372 

pernio, 371 

sclereux, 588 

sebaceus, 365 

snperficialis, 365 

tuberculosa, 37 1 

verrucosus, 372, 588 



Lupus vorax, 371 
vulgaris, 371 

diagnosis, 374 

etiology, 373 

pathology, 374 

prognosis, 378 

treatment, 375 
Lustseuche, 526 
Lympliadenie cutanee, 390 
Lymphangiectasis, 378 
Lymphangiectodes, 379 
Lymphangioma, 379 

tuberosum multiplex, 380 
Lymphangio-myoma, 392 
Lymphodermia perniciosa, 390 
Lymphorrhagica pachydermia, 379 

MACCHIE epatiche, 127 
Maculae cseruleae, 413 
et striae atrophica?, 115 
Macule, the, 27 
Madura foot, 285 
Mai de la rosa, 417 

de los pintos, 430 

roxo, 417 
Malingering, 277 
Malleus, 242 
Malum venereum, 525 
Mamillaris maligna, 404 
Marsden's paste, 618 
Mask, 127 
Masque, 127 
Measles, 387 

German, 4S4 
Meissner's corpuscles, 22 
Melanoderma, 127 
Melanosarcoma. 485 
Melanosis lenticularis progressiva, 

110 
Melasma, 127 
Melastearrhee, 130 
Melitagra, 206 
Mentagra, 516 
Microsporon anomseon, 433 

Audouini, 579 

furfur, 134 

minutissimum, 264 
Middlesex Hospital paste, 619 
Miliaria, 381 
Miliary fever, 383 
Milium, 383 
Milk crust, 206, 218 



INDEX. 



637 



Mite, mower's, 409 
Mitesser, 138 
Mole, pigmentary, 393 
Molluscum cholesterique, 605 

contagiosum, 385 

epitheliale, 385 

fibrosum, 278 

pendulum, 278 

sebaceum, 385 

sessile, 385 

simplex, 278 

verrucosum, 385 
Morbilli, 387 
Morbus elepbas, 226 

gallicus, 526 

hispanicus, 526 

indicus, 526 

italicus, 526 

maculosus Werlhoffii, 470 

neapolitanus, 526 

pedieularis, 411 
Morplicea, 501 
Morpion, 413 
Morvan's disease, 389, 565 
Morve, 242 
Moth patch, 127 
Mother's mark, 393 
Mucous patch, 534 
Muslin, plaster, 44 

salve, 44 
Myasis externa dermatosa, 389 
Mycetoma, 285 
Mycosis frambcesiodes, 178 

fungoi'des, 390 

microsporina, 132 
Myoma, 392 
Myronin, 47 
Myxcedema, 392 

ATiEVUS araneus, 567 



L\ 



flammeus, 396 
lipomatodes, 393 
nerve, 407 
pigmentosus, 393 
pilosus, 393 
sanguineus, 396 
simplex, 396 
spilus, 393 
tnberosus, 396 
unius lateris, 407 
vascularis, 396 
venous, 396 



Nsevus verrucosus, 393, 396 

Naftalan, 50 

Nails, anatomy of, 25 

atrophy of, 109 

ingrowing, 410 
Naphtol, 50 
Neoplasm, inflammatory fungoid, 

390 
Nerven naevus, 407 
Nerves, 22 
Nesselausschlag, 594 
Nesselsuch, 594 
Nettle rash, 594 
Neuralgia of the skin, 145 
Neuroma cutis, 399 
Nodosites non-£rythemateuses des 

arthritiques, 400 
Nodules, ephemeral cutaneous. 400 

subcutaneous rheumatismal, 
400 
Nodulus laqueatus, 400 
Noli me tangere, 234, 371 
Nosophen, 50 

/Tj^DEMA cutis, 400 
VXj neonatorum, 401 
CEsypus, 47 
Oleum chcenoceti, 46 

physeteiis, 46 
Onychatrophia, 109 
Onvchauxis, 402 
Onvchia, 403 
Onychitis, 403 
Onychogryphosis, 402 
Onychomycosis, 404, 576 
Ophiasis, 94 
Osmidrosis, 116 
Osteosis cutis, 404 

PACHYDERMATOCELE, 178 
Pachydermia, 226 
Pacinian corpuscles, 22 
Paget's disease of the nipple, 404 
Pain, 42 

Panaris nerveux, 407 
Panaritium, 410 
Panne hepatique, 127 
Panniculus adiposus, 21 
Papillar Geschwulste der Haut, 

beerschwamahnliche multiple, 

390 
Papilloma, 407 



638 



INDEX. 



Papilloma area elevatum, 407 

lineare, 407 

neuropathic, 407 

neuroticum, 407 
Papule, the, 29 
Parakeratosis scutularis, 409 

variegata, 409 
Parangi, 610 
Parasitic diseases, 409 
Paronychia, 410 
Pastes, 44 

Patients, examination of, 43 
Pedicularia, 411 
Pediculosis, 411 

diagnosis, 415 
etiology, 413 
treatment, 416 

capitis, 411 

pubis, 413 

vestimentornm, 412 
Pelade, 94 

Peliosis rheumatica, 470 
Pellagra, 417 
Pemfigo, 419 
Pemphigus, 419 

diagnosis, 424 
etiology, 423 
pathology, 423 
prognosis, 425 
treatment, 425 

a petites bulle, 159 

circinatus, 159 

contagiosus, 320, 421 

foliaceus, 422 

gangra?nosus, 158 

neonatorum, 421 

pruriginosus, 158, 422 

vegetans, 421 

vulgaris, 419 
Pencils, paste, 45 

salve, 45 
Perifolliculitis suppurees et con- 

glomerees en placards, 426 
Perisarcoma, 474 
Perleche, 428 
Pernio, 149 
Phagmesis, 429 
Phlegmesia malabarica, 226 
Phlyzacia agria, 180 
Phthiriasis, 411 
Phyto-alopecia, 94 
Pian, 610 



Pian ruboide, 171 
Piebald-skin, 348 
Piedra, 429 
Pigment, 19 
Pigmentflecken, 127 
Pigmentmal, 393 
Pimple, 63 
Pinta, 430 
Pityriasis, 507 

alba atrophicans, 431 

capitis, 437 

circine et margine, 432 

lichenoides chronica, 431 

maculata et circinata, 431 

nigricans, 130 

parasitaire, 132 

pilaris, 334 

rosea, 431 

rubra, 151 

pilaris, 434 

simplex, 437 

tabescentium, 438 

versicolor, 132 
Plasment, 46 
Plica Polonica, 438 
Plique polonaise, 438 
Podelcoma, 285 
Poils accidentels, 307 
Poison-ivy eruption, 174 
Poliosis, 119 
Poliotes, 119 
Poliothrix, 119 
Polyidrosis, 304 
Polytrichia, 307 
Pompholyx, 419, 439 
Porcellanfriesel, 594 
Porokeratosis, 441 
Porrigo, 206, 266 

contagiosa, 320 

decalvans, 94 

favosa, 266 

furfurans, 571 

lavalis, 266 

lupinosa, 266 

scutulata, 266 
Porrigophyta, 266 
Portvvine mark, 396 
Pox, 526 
Prairie itch, 443 
Prickly heat, 381 
Prurigo, 443 
Pruritus aestivalis, 448 



INDEX. 



639 



Pruritus cutaneus, 42, 447 
hiemalis, 448 
senilis, 448 
Pseudo-erysipelas, 452 
Pseudo-leucaemia cutis, 452 
Pseudo-lupus, 146 
Pseudo-xanthom elastique, 608 
Psora, 453 
Psoriasis, 453 

diagnosis, 459 
etiology, 457 
pathology, 458 
prognosis, 467 
treatment, 461 
buccalis, 351 
Psorospermose folliculaire v^ge"- 

tante, 331 
Psorospermosis follicularis cutis, 

468 
Pterygium, 468 
Pulex irritans, 410 
penetrans, 410 
Purpura, 468 
Pustula maligna, 473 
Pustule, the, 30 



Q 



UINQUAUm 
Quirica, 430 



disease, 283 



RAYNAUD'S disease, 157 
Red gum, 382, 474 
Eesorbin, 47 
Resorcin, 50 
Rete Malpighii, 19 
Rheumatism of skin, 145 
Rhinophyma, 474, 478 
Rhinoscleroma, 474 
Rhus-poisoning, 174 
Ringed eruptions, 35 
Ringskurv, 572 
Ringworm, 569 

crusted, 266 

honeycomb, 266 

of the beard, 575 

of the body, 569 

of the nails, 576 

of the scalp, 572 

Polish, 438 
Risipola, 243 

lombarda, 417 
Ritter's disease, 155 
Rodent ulcer, 234, 236 



Rogna grossa, 180 
Rosacea, 476 

diagnosis, 480 

etiology, 479 

pathology, 479 

prognosis, 484 

treatment, 480 
Rose, la, 243 
RosSe, 477 
Rose rash, 249 
Roseola, 252 

pityriaca, 432 

syphilitica, 530 
Rotheln, 484 
Rothlauf, 243 
Rotz, 242 
Rubeola, 387, 484 
Run-around, 410 
Rupia, 542 

escharotica, 158 

ST. ANTHONY'S fire, 243 
Salt rheum, 182 
Salzfluss, 182 
Sapolan, 50 

Sarcocele, Egyptian, 226 
Sarcoma, 485 

cutis multiple, 390 
Sarcomatosis generalis, 390 
Satyriasis, 340 
Sauriasis, 315 
Sauroderma, 468 
Scabies, 488 

diagnosis, 493 

etiology, 490 

pathology, 491 

prognosis, 496 

treatment, 493 
Scald head, 206, 266 
Scale, the, 32 
Scall or scald, 182, 206 
Scalp, hygiene of, 88 
Scar, hypertrophied, 329 

keloidal, 329 
Scarlatina, 496 
Schmeerfluss, 507 
Schuppenflechte, 453 
Scissura pilorum, 105 
Sclerem der Neugeboren, 497 
Sclerema adultorum, 498 

neonatorum, 497 
Sclereme des adults, 498 



640 



INDEX. 



Scleriasis, 498 
Sclerodactylie, 500 
Scleroderma, 498 

circumscribed, 501 

neonatorum, 497 
Sclerodermic, 498 
Scleroma adultorum, 498 
Sclerostenosis, 498 
Scrofulide boutonneuse benigne, 
443 

ervthemateuse, 365 

tuberculeuse, 371 
Scrofuloderma, 503 

ulcerative, 390 

verrucosum, 588 
Scurvy, land, 470 
Sebaceous glands, anatomy of, 25 
Seborrbagia, 507 
Seborrboea, 507 

diagnosis, 511 
etiology, 510 
prognosis, 515 
treatment, 513 

congestiva, 365 

nigricans, 130 
Seborrhceal eczema, 221 
Shingles, 611 
Sicosi parasitaria, 575 
Siderosis, 515 

Skin, anatomy and physiology of, 
17 

blood vessels of, 21 

cancer, 234 

lesions of, 27 

lymphatics of, 21 

muscles of, 27 

nerves of, 22 

neuralgia of, 145 

rheumatism of, 145 

splints, 45 
Smallpox, 601 

Soap, superoxide of soda, 627 
Soaps, medicated, 46 
Sommersprossen, 338 
Spargosis, 226 
Spedalskhed, 340 
Sphaceloderma, 156 
Spilosis poliosis, 119 
Spotted sickness, 430 
Startin's mixture, 617 
Stearrhoea, 507 

nigricans, 130 



Steatoma, 506 
Steatorrhea, 507 
Steresol, 51 

Stigmata, bleeding, 294 
Stonepock, 63 
Stratum corneum, 18 

mucosum, 19 
Stria? et macula? atrophica?, 115 
Strophulus, 382 
albidus, 383 
prtirigineux, 443 
Sudani ina, 381 
Sudatoria, 304 
Sudor urinosus, 594 
Sunburn, 147 
Sweat, blue, 130 

glands, anatomy of, 26 
green, 132 
red, 131 
yellow, 132 
Sweating, excessive, 304 
Swelling, giant, 400 

periodic, 400 
Sycosis, 516 

diagnosis, 520 
etiologv, 519 
pathology, 519 
prognosis, 525 
treatment, 521 
barbie, 516 
eapillitii, 170 
frambcesia, 171 
menti, 516 
non-parasitica, 516 
parasitaire, 575 
parasitica, 575 
Syphilis, 525 

diagnosis, 548 
etiology, 548 
pathology, 549 
prognosis, 564 
treatment, 553 
hereditary, 549 
secondary, 530 
tertiary, 537 
Syringocystadenoma, 242 
Syringomyelia, 565 

TACHE de feu, 396 
hepatique, 127 
ombrees, 413 
vasculaire, 396 



INDEX. 



641 



Tactile corpuscles, 22 
Tanne, 138 
Tar, 51 

acne, 78 
Tattoo, 565 
Teigne du pauvre, 266 

faveuse, 266 

pelade, 94 

tondante, 572 

tonsurante, 572 
Telangiectasis, 566 
Tetter, 182 
Therapeutic notes, 44 
Thilanin, 51 
Thiol, 51 
Thiosavonale, 51 
Tinctura saponis viridis, 622 
Tinea arniantacea, 507 

asbestina, 507 

barbae, 575 

circinata, 569 

decalvans, 94 

favosa, 266 

ficosa, 266 

imbricata, 570 

kerion, 336 

lupinosa, 266 

maligna, 266 

nodosa, 568 

sycosis, 575 

tondens, 571 

tonsurans, 571 

vera, 266 

versicolor, 132 
Tinna, 430 
Traumaticin, 44 
Trichauxis, 307 
Trichiasis, 568 
Trichoclasia, 106 
Trichoma, 438 
Trichomycosis nodosa, 429 
Trichomykosis capillitii, 336 

favosa, 266 
Trichonosis cana, 119 

discolor, 119 

poliosis. 119 
Trichophytie circinee, 569 

sycosique, 575 
Trichophyton tonsurans ectothrix, 
579 
endothrix, 579 
Trichophytosis, 569 
41 



Trichophytosis, diagnosis, 571, 574, 
576, 577 
etiology, 577 
pathology, 577 
prognosis, 586 
treatment, 579 
barbse, 575 
capitis, 571 
corporis, 569 
unguium, 576 
Trichoptylose, 106 
Trichorrhexis nodosa, 106 
Trichosis hirsuties, 307 
plica, 438 
poliosis, 119 
Tropical big leg, 226 
Tubercle, the, 29 

anatomical, 588 
Tuberculosis cutis, 587 

verrucosa cutis, 588 
Tuberculum sebaceum, 383 
Tumenol, 51 
Tumor, the, 32 

multiple fungoid papilloma- 
tous, 390 
Tyloma, 118 
Tylosis, 118 

lingua?, 351 

palma? et planta?, 333 

ULCER, 33, 590 
grave, 285 

perforating, of the foot, 426 

rodent, 234, 236 

scrofulous, 504 

syphilitic, 545 

tropical phagedenic, 593 
Ulerythema, 365, 593 

acneiforme, 593 

ophryogenes, 593 

sycosiforme, 284, 593 
Uridrosis, 594 
Urticaire, 594 
Urticaria, 594 

cedematosa, 401 

pigmentosa, 599 

VACCINAL eruptions, 600 
Varicella, 601 

gangrenosa, 158 
Variola, 601 
Varioloid, 601 - 



642 



INDEX. 



Varus, 63 
Vasogen, 47 

Venereal wart, 603 
Verole, 526 
Verruca, 602 

necrogenica, 588 
Verrue, 602 

telangiectasia, ne, 102 
Verruga, endemic, 610 

Peruana, 604 
Vesicle, the, 30 
Vienna paste, 619 
Vitiligo, 348 

capitis, 94 
Vitiligoidea, 605 
Vleminckx's solution, 623 

WART, 602 
Warts, post-mortem, 588 
telangiectatic, 102 
Warze, 602 

Washerwoman's itch, 213 
Washleather skin, 605 



Weichselzopf, 438 
Wen, 506 

Wheal, the, 31 
Whelk, 63 
Whitlow, 403, 410 
melanotic, 486 
Wildfire, 243 

Wilkinson's ointment, 626 
Wundrose, 243 

XANTHELASMA, 605 
Xanthela.snioi.lea, 599 
Xanthoma, 605 

diabeticorum, 609 
Xeroderma, 315 

pigmentosum, 110 
Xerodermic pilaire, 334 
Xeroform, 51 

VAWS, 610 



r OXA, 611 

i Zoster, 611 



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INDEX. 

ANATOMY. Gray, p. 11 ; Treves, 30 ; Gerrish, 11; Brockway, 4. 

DICTIONARIES. Dunglison, p. 9 ; Duane, 8 ; National, 4. 

PHYSICS. Draper, p. 8 ; Martin & Rockwell, 19. 

PHYSIOLOGY. Foster, p. 10; Chapman, 5; Schofield, 25; Collins 
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PRACTICE. Flint, p. 10 ; Loomis & Thompson, 18 ; Malsbary, 19 ; 
Thompson, 29. 

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CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. 

NERVOUS DISEASES. Dercum, p. 8 ; Potts, 23. 

MENTAL DISEASES. Clouston, p. 6 ; Folsom. 10. 

BACTERIOLOGY. Abbott, p. 2 ; Vanghan & Novy, 30 ; Senn's 
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DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. A new American, from the twelfth London 
edition, edited by Stanley Boyd, F. R. C. S. In one large octavo 
volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. 

DUANE (ALEXANDER). A DICTIONARY OF MEDICINE AND 
THE ALLIED SCIENCES. Comprising the Pronunciation, Deriva- 
tion and Full Explanation of Medical, Dental, Pharmaceutical and 
Veterinary Terms. Together with much Collateral Descriptive Mat- 
ter. Numerous Tables, etc. New (3d) edition. Square octavo of 652 
pages, with 8 colored plates. Just ready. Cloth, $3.00, net; limp 
leather, $4.00, net. 

DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF 

GYNECOLOGY. New (2d) edition. Handsome octavo of 717 pages, 

with 453 illustrations in black and colors, and 8 colored plates. Cloth, 

$5.00, net; leather, $6.00, net; half Morocco, $6.50, net. Just ready. 

The book can be safely recom- j tice of modern gynecology. — Inter- 

mended as a complete and reliable national Jlcdical Magazine. 

exposition of the principles and prac- | 

DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 
DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 

DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. 
The best one-volume text or refer- 1 of published in America.— Virginia 
ence book on histology that we know ' 3Iedical Sem i-Mo n th ly. 

NORMAL HISTOLOGY. New (2d) edition. Octavo, 319 pages, 

with 244 illustrations. Just ready. Cloth, $2.50, net. 



scarcely be measured. — Med. Record. 
Pronunciation is indicated by the 
phonetic system. The definitions are 
unusually clear and concise. The 
book is wholly satisfactory. — Uni- 
versity Medical Magazine. 



Lea Beothkhs & Co., Philadelphia and New York. 9 

DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology ; Medical Chemistry, Pharmacy, Phar- 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. 
By Robley Dunglison, M. D., LL. D., late Professor of Institutes 
of Medicine in the Jefferson Medical College of Philadelphia. Edited 
by Richard J. Dunglison, A. M., M. D. Twenty-second edition, thor- 
oughly revised and greatly enlarged and improved, with the Pronuncia- 
tion, Accentuation and Derivation of the Terms. With Appendix. 
In one magnificent imperial octavo volume of 1350 pages. Just 
ready. Cloth, $7.00, Net; leather, $8.00, Net. This edition contains 
portrait of Dr. Dunglison. Notices of previous edition are appended. 
The most satisfactory and authori- 
tative guide to the derivation, defini- 
tion and pronunciation of medical 
terms. — The CharlotteMed. Journal. 
Covering the entire field of medi- 
cine, surgery and the collateral 
sciences, its range of usefulness can 
EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
leather, $4.50. 
EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
with 148 engravings. Cloth, $3 ; leather, $4. 
EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
TATION. In one 12mo. volume of 359 pages, with 63 illustrations. 
Cloth, Net, $2.25. 

ligence. The writer has adapted it 
to American conditions, and his 
suggestions are, above all, practical. 
— The New York Medical Journal. 

ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY. 
Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, 
$4.25 ; leather, $5.25. 

EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
TICE OF GYNECOLOGY. Third edition. Octavo, 880 pages, with 
150 original engravings. Cloth, $5 ; leather, $6. 

ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- 
GERY. Eighth edition. In two large octavo volumes containing 
2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American 
Text-Books of Dentistry, page 2. 

EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 
In one handsome 12mo. volume of 409 pages, with 148 illustrations. 
Just ready. Cloth, $1.75, JSet; limp leather, $2.25, Net. Lea's Series 
of Pocket Text-books, edited by Bern B. Gallaudet, M.D. See p 18. 

PARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 
Fourth American from fourth English edition, revised by Franz 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 



It is written in plain language, 
and, while primarily designed for 
physicians, it can be studied with 
profit by any one of ordinary intel- 



10 Lea Brothers & Co., Philadelphia and New York. 

FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
engravings and 21 colored plates. Cloth, $3.75. 

FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 

PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 

by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 

pages, with engravings. Cloth. $5.00; leather, $6.00. 

The work has well earned its lead- The best of American text-books 

ing place in medical literature. — on Practice. — Amer. Medico-Surgical 

Medical Record. Bulletin. 

A MANUAL OF AUSCULTATION AND PERCUSSION; of 

the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

A PRACTICAL TREATISE ON THE DIAGNOSIS AND 

TREATMENT OF DISEASES OF THE HEART. Second edition 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. 

A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 

FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. "With Clouston on Mental Diseases (new edition, see 
page 6) $5.00, net, for the two works. 

FORMULARY, POCKET, see page 32. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 

(6th) and revised American from the sixth English edition. In one 

large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; 

leather, $5.50. 

Unquestionably the best book that This single volume contains all 

can be placed in the student's hands, I that will be necessary in a college 

and as a work of reference for the I course, and all that the physician 

busy physician it can scarcely be will need as well. — Dominion Med. 

excelled. — The Phi I a. Polyclinic. j Monthly. 

FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND- 
BOOK OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 

FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
bodying Watts' Physical and Inorganic Chemistry. In one royal 
12m"o. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 

FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 
In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 

FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
pages. Cloth, $3.50. 



Lea Bbothers & Co., Philadelphia and New York. 11 



FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. 
It is an interesting work, and one I pathology and rational treatment to 

which is timely and needed. — Medi- many cases of sexual disturbance 

cal Fortnightly. whose treatment has been too often 

The book is valuable and instruc- fruitless for good. — Annals of 

tive and brings views of sound | Surgery. 

GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR- 
GERY. In one handsome 12mo. volume of about 400 pages, with many 
illustrations. Shortly. Lea's Series of Pocket Text-books, edited by 
Bern B. Gallaudet, M. D. See page 17. 

GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
imp. octavo volume of 915 pages, with 950 illustrations in black and 
colors. Cloth, $6.50; flexible waterproof, $7; leather, $7.50, net; 
half Morocco, $8.00, net. 



The illustrations far outnumber 
and exceed in size and in profusion 
of colors those in any previous work ; 
and they can well claim to be the 
most successful series of anatomical 
pictures in the world. — The Ameri- 
can Practitioner and News. 

The chief merit in the book will 

be found in the descriptive text, 

which is accurate, concise, and gives 

the essentials of descriptive anatomy 

with less waste of words and better 

emphasis of important points than 

GD3BES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID 
HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. 

GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 
New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7 ; leather $8. Price 
of edition with illustrations in black : cloth, $6 ; leather, $7. 



any similar text-book with which 
we are familiar. — The Boston Med/i- 
cal and Surgical Journal. 

We believe that this volume not 
only takes rank with all other works 
on anatomy, but in some respects is 
superior to any now available. — The 
Chicago Medical Recorder. 

There is nothing with which to 
find fault, everything to praise. The 
work is the most remarkable and 
most valuable volume of the year. — 
Buffalo Medical Journal. 



This is the best single volume 
upon Anatomy in the English 
language. — University Medical Mag- 
azine. 

Gray's Anatomy affords the student 
more satisfaction than any other 
treatise with which we are familiar. 
— Buffalo Med. Journal. 

The most largely used anatomical 
text-book published in the English 
language. — Annals of Surgery. 

Particular stress is laid upon the 
practical side of anatomical teach- 



ing, and especially the Surgical 
Anatomy. — Chicago Med. Recorder. 

Holds first place in the esteem of 
both teachers and students. — The 
Brooklyn Medical Journal. 

The foremost of all medical text- 
books. — Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro- 
fessional career. — Pittsburg Medical 
Review. 



12 Lea Brothers & Co., Philadelphia and New York. 



GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 

GREEN (T. HENRY). PATHOLOGY AND MORBID ANATOMY 
New (8th) American from the eighth London edition. In one hand- 
some octavo volume of 582 pages, with 216 engravings and a colored 
plate. Cloth, $2.50, net. 
A work that is the text-book of The work is an essential to the 
probably four-fifths of all the stu- practitioner — whether as surgeon or 
dents of pathology in the United physician. It is the best of up-to- 
States and Great Britain. — The date text-books. — Virginia Medical 
American Practitioner and News. ' Monthly. 

GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- 
ISTRY. For the Use of Students. Based upon Bowman's Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 

GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. 

GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN 
DISEASES. In one handsome 12mo. volume of 350 pages, with 
many illustrations. Shortly. Lea's Series of Pocket Text-books, edited 
by Bern B. Gallaudet, M. D. See page 18. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN 
Second American from the third English edition. In one octavo vol- 
ume of 554 pages, with 11 engravings. Cloth, $3.50. 

HALL (WLNFIELD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo 

of 672 pages, with 343 engravings, and 6 full page colored plates. 

Cloth, $4.00 ; leather, $5.00, net. 
Truly a scientific treatment of the of which needs to be more strongly 
subject The clearness with which ! impressed upon students A book 
physiological facts are demonstrated ! which makes this so easily possible 
makes it of special value to the is to be highly commended. — West- 
medical student. The science of em Medical Review. 
physiology is one, the importance 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 

HARD AW AX (W. A.). MANUAL OF SKIN DISEASES. New (2d) 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. 
The best of all the small books to j day clinical experience. His great 
recommend to students and practi- I strength is in diagnosis, descriptions 
tioners. Probably no one of our of lesions and especially in treat- 
dermatologists hashad a wider every- ! ment. — Indiana Medical Journal. 

HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- 
TIONS AND SEQUEL/E OF TYPHOID FEVER. Octavo, 276 
pages, 21 engravings and two full-page plates. Cloth, $2.40, net. 
A very valuable production. One read with great profit. — Cleveland 

of the very best products of Dr. I Journal of Medicine. 

Hare and one that every man can ' 



Lea Brothers & Co., Philadelphia and New York. 13 



HARE (HOBAET AMORY). PEACTICAL DIAGNOSIS. THE 
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New 
(4th) edition. In one octavo volume of 623 pages, with 205 engravings 



and 14 full-page colored plates. 
$6.50, net. 

It is unique in many respects, and 
the author has introduced radical 
changes which will be welcomed by 
all. Anyone who reads this book 
will become a more acute observer, 
will pay more attention to the simple 
yet indicative signs of disease, and 



Cloth, $5.00, net; half Morocco, 

he will become a better diagnosti- 
cian. This is a companion to Prac- 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 
utility. — Medical Review. 



HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL 
THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New (8th) and revised edition. In one octavo volume of 796 pages, 
with 37 engravings and 3 coloi-ed plates. Cloth, $4.00, net; leather, 
$5.00, net; half Morocco, $5.50, net. Just ready. 

it can be readily used in connection 



Its classifications are inimitable, 
and the readiness with which any- 
thing can be found is the most won- 
derful achievement of the art of in- 
dexing. This edition takes in all 
the latest discovered remedies. — 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy reference 
work. It has been arranged so that 



with Hare's Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
— Medical Sentinel. 

The best planned therapeutic work 
of the century. — American Prac- 
titioner and News. 

It is a book precisely adapted to 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs. — The National Med- 
ical Review. 



HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages,with about 550 engravings. Vol. IV., now ready. For sale by sub 
scription only. Full prospectus free on application to the Publishers 
Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8 
Price Vol. IV. to former or new subscribers to complete work, cloth 
$5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20; leather 
$24 ; half Russia, $28. 

The great value of Hare's System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new corps 
of equally eminent authors, so that entirely fresh and original matter is 
ensured. The plan of the work, which proved so successful, has been fol- 
lowed in this new volume, which will be found to present the latest devel- 
opments and applications of this most practical branch of the medical art. 
The entire System is an unrivalled encyclopaedia on the practical parts of 
medioine, and merits the great success it has won for that reason. 



14 Lea Brothers & Co., Philadelphia and New York. 

HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth editiou. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75 . 

A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 

12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 

Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery aud Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. 

HAYDEN (JAMES R). A MANUAL OF VENEREAL DISEASES. 
New (2d) editiou. In one 12mo. volume of 304 pages, with 54 en- 
gravings. Cloth, $1.50, aft. 

It is practical, concise, definite I It is well written, up to date, and 
and of sufficient fulness to be satis- will be found very useful. — Inter- 
factory. — Chicago Clinical Review. ' national Medical Magazine. 

HAYEM (GEORGES) AND HARE (H. A). PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages, with 113 engravings. Cloth, $3. 

This well-timed volume is particu- tific information on the subject. 
larly adapted to the requirements Altogether this work is the clearest 
of the general practitioner. The i and most practical aid to the study 
section on mineral waters is most of nature's therapeutics that has yet 
scientific and practical. Some 200 ! come under our observation. — The 
pages are given up to electricity and Medical Fortnightly. 
evidently embody the latest scien- ' 

HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 
one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 

HERMANN (Ij.). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. 
volume of 199 pages, with 32 engravings. Cloth, $1.50. 

HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 
one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 

We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag- 
nosis in the exigencies of professional 
life. — Memphis Medical Monthly. 



Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac- 
titioner as well as of the student. — 
Chicago Med. Recorder. 



HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 



Lea Brothers & Co., Philadelphia and New York. 15 

HILMER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON O.) AND PD3RSOL (GEORGE A.). HUMAN 

MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. Limited edition. For sale 
by subscription only. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
New (13th) edition. In one 12mo. volume of 845 pages. Cloth, 
$3.00, net. Just ready. 

HODGE (HUGH It). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- 
ume of 1008 pages, with 428 engravings. Cloth, $6 ; leather, $7. 

A SYSTEM OF SURGERY. With notes and additions by various 

American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7.50. For sale by subscription only. 

HORNER (TVTLLIAM E.). SPECIAL ANATOMY AND" HIS- 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 



HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one 
octavo volume of 308 pages. Cloth, $2.50. 

HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL 
METHODS. A GUIDE TO THE PRACTICAL STUDY OF 
MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- 
ings and 8 colored plates. Cloth, $3.00. 

A comprehensive, clear and re- i plentiful and excellent. — Montreal 
markably up-to-date guide to clinical Medical Journal. 
diagnosis. The illustrations are I 



16 Lea Brothers & Co., Philadelphia and New York. 

HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- 
EASES OF THE SKIN. New (5th) edition, thoroughly revised. 
Octavo, 866 pages, with 111 engravings and 24 full-page plates, 8 of 
which are colored. Just ready. Cloth, $4.50, net; leather, $5.50, net; 
half Morocco, $6.00, net. 

culcated throughout is sound as well 
as practical. — The American Jour- 
nal of the Medical Sciences. 

It is the best one-volume work 
that we know. — Virginia Medical 
Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg 3fedical Review. 

The most practical handbook on 
dermatology with which we are ac- 
quainted. — Chicago Medical Re- 
corder. 



This edition has been carefully re- 
vised, and every real advance has 
been recogoized. The work answers 
the needs of the general practitioner, 
the specialist, and the student. — The 
Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. 
In one 12mo. volume of 637 pages, with 75 illustrations and a colored 
plate. Cloth, $2.50, net. 

As a student's manual, it may be I Without doubt forms one of the 
considered beyond criticism. The best guides for the beginner in der- 
book is singularly full. — St. Louis matology that is to be found in the 

Medical and Surgical Journal. j English language. — Medicine. 

JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 

JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 
12mo. volume of 356 pages, with 80 engravings and 3 colored plates. 
Cloth, $2.25. 
An exceedingly useful manual for I ing it in attractive and easily tangi- 

student and practitioner. The au- ble form. The book is well illus- 

thor has succeeded unusually well trated throughout. — Nashville Jour. 

in condensing the text and in arrang- ' of Medicine and Surgery. 

THE PRACTICE OF OBSTETRICS. By American Authors. 

One large octavo volume of 76-" pages, with 441 engravings in black 

and colors, and 22 full-page colored plates. Cloth, $5.00, net; 

leather, $6.00, net; half Morocco, $6.50, net. 

A clear and practical treatise upon the book abounds. The work is 

obstetrics by well-known teachers of sure to be popular with medical 

the subject. A special feature of students, as well as being of extreme 

this work would seem to be the value to the practitioner. — The 

excellent illustrations with which Medical Age. 

JONES (C. HANDF1ELD). CLINICAL OBSERVATIONS ON 
FUNCTIONAL NERVOUS DISORDERS. Second American edi- 
tion. Iujone octavo volume of 340 pages. Cloth, $3.25. 



Lea Brothers & Co., Philadelphia and New York. 17 

JIILER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PRACTICE. Second edition. In one octavo volume of 549 
pages, with 201 engravings, 17 chromo-lithographic plates, test-types of 
Jaeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 
The volume is particularly rich in color blindness, etc. The sections 

matter of practical value, such as devoted to treatment are singularly 

directions for diagnosing, use of full and concise. — Medical Age. 

instruments, testing for glasses, for 

KING (A.F. A.). A MANUAL OF OBSTETRICS. New (8th) edition. 
In one 12mo. volume of 612 pages, with 264 illustrations. Cloth, 
$2.50, net. Just ready. 



From first to finish it is thoroughly 
practical, ooncise in expression, well 
illustrated, and includes a statement 
of nearly every fact of importance 
discussed in obstetric treatises or 



cyclopedias. The well-arranged 
index renders the book useful to 
the practitioner who is in haste to 
refresh his memory. — Virginia 
Medical Semi-Monthly. 



KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome 
octavo of 700 pages, with 751 illustrations. See American Text-Books 
of Dentistry, page 2. 



tempted. We can heartily recom- 
mend it to the profession. — The 
Ohio Dental Journal. 



We have only the highest praise 
for this valuable work. It is replete 
in every particular, and surpasses 
anything of the kind heretofore at- 

KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, 
net. See Student's Series of Manuals, page 27. 



It is the most complete and con- 
cise work of the kind that has yet 
emanated from the press. — The Med- 
ical Age. 



This work deservedly occupies a 
first place as a text-book on his- 
tology. — Canadian Practitioner. 



L.ANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 

handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 

LEA'S SERIES OP POCKET TEXT-BOOKS, edited by Bern 
B. Gallaudet, M. D. Covering the entire field of Medicine in a 
series of 16 very handsome 12mo. volumes of 350-450 pages each, 
profusely illustrated. Compendious, clear, trustworthy and modern. 
The following volumes constitute the series. 

Coates' Bacteriology and Hygiene. Brockway's Anatomy. Collins 
and Rockwell's Physiology. Martin and Rockwell's Chemistry 
and Physics. Nichols and Vale's Histology and Pathology. 
Schleif'S Materia Medica, Therapeutics, Medical Latin, etc. Mals- 
bary's Practice of Medicine. Collins' Diagnosis. Potts' Nervous 
and Mental Diseases. Gallaudet's Surgery. Grindon's Der- 
matology. Wippern and Ballenger's Diseases of the Eye, Ear, 
Throat and Nose. Evans' Obstetrics. Crockett's Gynecology. 
Tdttle's Diseases of Children. 

For separate notices see under various authors' names. 



18 Lea Brothers & Co., Philadelphia and New York. 

LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 

CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI- 
THE ENDEMONIADAS ; EL SANTO NlRO DE LA GUARDIA; 
BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50. 

FORMULARY OF THE PAPAL PENITENTIARY. In one 

octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 

SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 

OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughly revised. In one hand- 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 

STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 

AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
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LOOMIS (ALFRED It.) AND THOMPSON (W. GILMAN, 
EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 
Contributions by Various American Authors. In four very hand- 
some octavo volumes of about 900 pages each, fully illustrated in 
in black and colors. Complete work notv ready. Per volume, cloth, 
$5 ; leather, $6 ; half Morocco, $7. For sale by subscription only. 
Full prospectus free on application to the Publishers. See American 
System of Practical Medicine, page 2. 

LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 
very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 

Complete, concise, fully abreast of I An exceedingly valuable text-book, 
the times and needed by all students Practical, systematic, and well bal- 
and practitioners. — Univ. Med. Mag. ' anced. — Chicago Med. Recorder. 

LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
volume of 362 pages. Cloth, $2.25. 

MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. 
Handsome octavo, about 600 pages, richly illustrated. Preparing. 



Lea Brothers & Co., Philadelphia and New York. 19 



MAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. New (7th) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 
285 engravings. Cloth, $2.50, net. 



Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col- 
leges. — American Therapist. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 



in America. The work has no equal. 
— Dominion Med. Monthly. 

The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. & Sur. Jonr. 



MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF 
THEORY AND PRACTICE OF MEDICINE. In one handsome 
12mo. volume of 405 pages, with 45 illustrations. Just ready.. Cloth, 
$1.75, net; flexible red leather, $2.25, net. Lea's Series of Pocket 
Text-books, edited by Bern B. Gallaudet, M. D. See page 17. 



Will readily commend itself to 
students and busy practitioners, 
bringing forward as it does the most 
recent advances in medicine with 
the best of that which is old. It 



deals briefly and systematically with 
each disease, as to its history, fetiol- 
°§Y> symptomatology, diagnosis, 
prognosis and treatment. — Medical 
Review of Reviews. 



MANUALS. See Student's Quiz Series, page 27, Student's Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 



MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 
In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 

MARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET 
TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- 
some 12mo. volume of 366 pages, with 137 illustrations. Just ready. 
Cloth, $1.50, net; limp leather, $2.00, net. Lea's Series of Pocket 
Text-Books, edited by Bern B. Gallatjdet, M. D. See page 17. 

rately reflects both sciences in their 
present development. The arrange- 
ment of the matter is excellent. — 



Contains everything of the sci- 
ences of chemistry and physics 
necessary for the medical student 
and practitioner. The work accu- 



The Medical and Surgical monitor. 



MAY (O. H.). MANUAL OF THE DISEASES OF WOMEN. For 
the use of Students and Practitioners. Second edition, revised by L. 
S. Ratj, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 

MEDICAL NEWS POCKET FORMULARY, seepage; 32. 



20 Lea Brothers & Co., Philadelphia and New York. 

MITCHELL. (S. WEIR). CLINICAL LESSONS ON NERVOUS 
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Cloth, $2.50. 

The book treats of hysteria, recur- I contractions, rotary movements in 
rent melancholia, disorders of sleep, j the feeble minded, etc. Few can 
choreic movements, false sensations speak with more authority than the 
of cold, ataxia, hemiplegic pain, I author. — The Journal of the Ameri- 
treatment of sciatica, erythromelal- , can Medical Association. 
gia, reflex ocularneurosis, hysteric i 

MITCHELL. (JOHN K.). REMOTE CONSEQUENCES OF IN- 
JURIES OF NERVES AND THEIR TREATMENT. In one 

handsome 12mo. volume of 239 pages.with 12 illustrations. Cloth, $1.75. 



3IORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. 

The work is essentially clinical I strong common sense. It is alike 
and practical in its scope and is I suitable for the student, physician 
characterized throughout by clear- j and specialist. — Buffalo Medical 
ness and simplicity of style and 1 Journal. 



MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- 
OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. 

MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 
DIAGNOSIS, for Students and Physicians. New (3d) edition, thor- 
oughly revised. In one octavo volume of 1082 pages, with 253 en- 
gravings and 48 full-page colored plates. Cloth, $6.00, net; leather, 
$7.00, net; half Morocco, $7.50, net. 

We have no work of equal value It so thoroughly meets the precise 

in English. — University Medical demands incident to modern research 

Magazine. that it has been adopted as the lead- 

From its pages may be made the in g text-book by the medical colleges 

diagnosis of every malady that of thls . country.— North American 

afflicts the human body, including Practitioner. 

those which in general are dealt The best of its kind, invaluable to 

with only by the specialist. — North- the student, general practitioner and 

western Lancet. teacher. — Montreal Medical Journal. 



NATIONAL DISPENSATORY. See Stille, Maisch & Caspari, p. 27. 

NATIONAL FORMULARY. See Stille, Maisch & Campari's National 
Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 



Lea Brothers & Co., Philadelphia and New York. 21 



NETTLiESHIP (B.). DISEASES OF THE EYE. New (6th) American 
from sixth English edition, thoroughly revised. In one 12mo. volume 
of 562 pages, with 192 engravings, and 5 colored plates, test-types, 
formulae and color-blindness test. Cloth, $2.25, net. Just ready. 



The present edition is the result 
of revision both in England and 
America, and therefore contains the 
latest and best ophthalmological 
ideas of both continents. — The Phy- 
sician and Surgeon. 



By far the best student's text-book 
on the subject of ophthalmology. — 
The Clinical Review. 

This work for compactness, practi- 
cality and clearness has no superior 
in the English language.— Journal 
of Medicine and Science. 

NICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT- 
BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 
12mo. volume of 452 pages, with 213 illustrations. Just ready. Cloth 
$1.75, net: flexible red leather, $2.25, net. 

Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet 
M. D. See page 17. 

So systematically arranged that it can safely and conscientiously 

is, in the highest degree, interesting, ommend it to both students and 

Thoroughly up to date. The book practitioners. — The St. Louis Medi- 

is an exceptionally good one. We cal and Surgical Journal. 

NORRIS (¥M. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 



has ever been offered to the Amer- 
ican medical public. — Annals of 
Ophthalmology and Otology. 



It is practical in its teachings. 
We unreservedly endorse it as the 
best, the safest and the most compre- 
hensive volume upon the subject that 

OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 
In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 

PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. New and condensed edition. In one royal octavo 
volume of 1261 pages, with 625 engravings and 37 full-page plates. 
Cloth, $6.00, net ; leather, $7.00, net. 

^i^This work is also published in a larger edition, comprising two 
volumes. Volume I., General Surgery, 799 pages, with 356 engravings 
and 21 full-page plates, in colors and monochrome. Volume II., 
Special Surgery, 800 pages, with 430 engravings and 17 full-page 
plates, in colors and monochrome. Per set, cloth, $9.00 ; leather, 
$11.00, net; half Morocco, $12.00, net. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
upon treatment are 



clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

It is thoroughly practical and yet 
thoroughly scientific. — Med. News. 



22 Lea Brothehs & Co., Philadelphia and New Yoek. 

PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND 
SURGERY. 12mo., 688 pages, with 87 illustrations in black and 
colors, and 2 plates. Cloth, $3.00 net. 

This book fills a very distinct ! of view of the hygienist and public 
gap. None of the text-books in our health officer. The work is correct 
language take up the subject of bac- and very well up to date. — TheMon- 
teriology so thoroughly and so treal Medical Journal. 
Boundly as does this from the point 

PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 

PARVTN (THEOPHILUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 

Parvin's work in practical, con- , English language. — Medical Fort- 
cise and comprehensive. We com- nightly. 
mend it as first of ite class in the | 

PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 
Series of Manuals, page 27. 

SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 

with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 
In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Seventh American from the ninth 
English edition. In one octavo volume of 700 pages, with 207 
engravings and 7 plates. Cloth, $3.75 net ; leather, $4.75, net. 

An epitome of the science and a safe guide to both student and 
practice of midwifery, which em- obstetrician. It holds a place among 
bodies all recent advances. — The the ablest English-speaking authori- 
Medical Fortn ightly. ties on the obstetric art. — Buffalo 

This work must occupy a fore- , Medical and Surgical Journal. 
most place in obstetric medicine as j 

THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
TION AND HYSTERIA. In one 12mo. volume of 97 pages 
Cloth, $1. 



Lea Brothers & Co., Philadelphia and New York. 23 

POCKET FORMULARY, see page 32. 

POCKET TEXT-BOOKS, see page 18. 

POL.ITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Second American from the 
third German edition. Translated by Oscar Dodd, M. D., and 
edited by Sir William Dalby, F. R. C. S. In one octavo volume of 
748 pages, with 330 original engravings. 

POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS 
AND MENTAL DISEASES. In one handsome 12mo. volume of 
445 pages, with 88 engravings. Just ready. Cloth, $1.75, net; limp 
leather, $2.25, net. Lea's Series of Pocket Text-books, edited by 
Bern B. Gallaitdet, M. D. See page 17. 

Dr. Potts has succeeded in de- of the numerous discoveries in every 

picting the main facts in a manner branch of neurology is clearly pre- 

that will be appreciated by students sented. The book is a reliable guide. 

and general practitioners. The gist — The Medical Bulletin. 

PROGRESSIVE MEDICINE, see page 32. 

PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 

PYE-SMITH (PHELD? H.). DISEASES OF THE SKIN. In one 
12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERD3S. See Student's Quiz Series, page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 
12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals, page 27. 

RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND SURGERY.- In one 
imperial octavo volume of 640 pages, with 64 plates and numerous 
engravings in the text. Strongly bound in leather, $7. 

REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- 
ISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol- 
ume of 326 pages. Cloth, $2. 

A clear and concise explanation student of chemistry or the practi- 

of a difficult subject. We cordially tioner who desires to broaden his 

recommend it. — The London Lancet, theoretical knowledge of chemistry. 

The book is equally adapted to the —New Orleans Med. and Surg. Jour. 



24 Lea Brothers & Co., Philadelphia and New York. 

RICHARDSON (BENJAMIN WARD). PREVENTIVE MED1- 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. New (2d) edition. In one octavo volume of 
838 pages with 473 engravings and 8 plates. Just ready. Cloth, $4.25, 
net; leather, $5.25, net. 

A clear, concise, comprehensive j satisfactory or valuable single vol- 
and practical presentation of the ' ume work on this subject. — Pacific 
most modern surgery. The student i Medical Journal. 
or practitioner will not find a more I 



ROBERTS (SLR WILLIAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pagee, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 

SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
OGY. DESCRIPTIVE AND PRACTICAL. For the use of Students. 
New (5th) edition. In one handsome octavo volume of 359 pages, 
with 392 illustrations. Cloth, $3.00, net. 

Nowhere else will the same very The most satisfactory elementary 

moderate outlay secure as thoroughly text-book of histology in the Eng- 

useful and interesting an atlas of lish language. — The Boston Med. and 

structural anatomy. — The American Sur. Jour. 
Journal of theXe'dical Sciences. 



A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. 

In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 

SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, 
PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo., 
352 pages. Cloth, $1.50, net; flexible red leather, $2.00, net. Just 
ready. Lea's Series of Pocket Text-books. Edited by Bern B. 
Gallatjdet, M. D. See page 17. 

"We commend the book for it con- college courses on Materia Medica 

tains in a concise, definite, and as- and Therapeutics. — The National 

similable form the essential knowl- Medical Review. 
edge recpaired in the most complete 



Lea Brothers & Co., Philadelphia and New York. 25 

SOHMITZ AND ZUMPT'S CLASSICAL SERIES. Advanced 
Latin Exercises. Cloth, 60 cts. Schmidt's Elementary Latin Exer- 
cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 
cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. 

SCHOFD3LD (ALFRED T.). ELEMENTARY PHYSIOLOGY 
FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 
engravings and 2 colored plates. Cloth, $2. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
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550 pages, well illustrated. The following volumes are now ready : 
Yeo on Food in Health and Disease, new (2d) edition, $2.50; Carter 
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Joints, $2; Owen on Surgical Diseases of Children, $2; Pick on 
Fractures and Dislocations, $2 ; Savage on Insanity and Allied Neu- 
roses, $2. 
For separate notices, see under various authors' names. 

SERIES OF STUDENT'S MANUALS. See page 27. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- 
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one very handsome octavo volume of 563 pages, with 138 engravings 
and 18 full-page colored plates. Cloth, $3.50, net. Just ready. 

In all respects entirely up to date. 
— Medical Record. 

The chapter on examination or 
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titioner. 



This book thoroughly deserves its 
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tic and useful manual of the micro- 
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Very excellent colored plates illus- 
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Journal. 



SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. New (6th) 
edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 
plates showing colors of 64 tests. Cloth, $3.00, net. 



It is difficult to see how a better 
book could be constructed. No man 
who devotes himself to the practice 
of medicine need know more about 
chemistry than is contained between 



the covers of this book. — The North- 
western Lancet. 

Its statements are all clear and its 
teachings are practical. — Virginia 
Med. Monthly. 



26 Lea Brothers & Co., Philadelphia and New York. 

SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME- 
DIABLE STAGES. In one Svo. volume of 253 pp. Cloth, $2.25. 

SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. Eighth edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; 
leather, $5.50. 
A safe guide for students and phy- The most complete and satisfac- 

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For years the leading text-book on acquainted. — American Gynecologi- 

children's diseases in America. — cal and Obstetrical Journal. 

Chicago Medical Recorder. 

SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 
One of the most satisfactory works | dium for the modern surgeon. — Bos- 
on modern operative surgery yet ton Jledical and Surgical Journal. 
published. The book is a compen- | 

SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- 
TOLOGY. In one handsome octavo volume of 462 pages, with en- 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 

Every practitioner of medicine l A clear and lucid summary of 
should possess himself of a copy and what is known of climate in relation 
study it, and we are sure he will to its influence upon human beings, 
never regret it. — St. Louis Medical I — The Therapeutic Gazette, 
and Surgical Journal. 

STILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- 
MENT. In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 

THERAPEUTICS AND MATERIA MEDICA. Fourth and 

revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10; leather, $12. 

STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI 
(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer- 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the new U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the new edition of the National Formu- 
lary. In one magnificent imperial octavo volume of about 2025 pages, 
with 320 engravings. Cloth, $7.25; leather, $8. With ready reference 
Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 



Lea Brothers & Co., Philadelphia and New York. 27 

STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 

New (4th) edition. In one royal 12mo. volume of 581 pages, with 293 

engravings. Cloth, $3.00, net. Just ready. 
A useful and practical guide for I The book is worth the price for the 
all students and practitioners. — Am. illustrations alone. — Ohio Medical 
Journal of the Medical Sciences. \ Journal. 

STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 
DISLOCATIONS. In one handsome octavo volume of 831 pages, 
with 326 engravings and 20 plates. Cloth, $5.00, net; leather, 
$6.00, net; half Morocco, $6.50, net. 

pensable to the student and the prac- 



Preeminently the authoritative 
text-book upon the subject. The 
vast experience of the author gives 
to his conclusions an unimpeachable 
value. The work is profusely il- 
lustrated. It will be found indis- 



iitioner alike. — The Medical Age. 

The work is the best one in Eng- 
lish to-day. — St. Louis Medical and 
Surgical Journal. 



STUDENT'S QUIZ SERIES. Thirteen volumes, convenient, author- 
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STUDENT'S SERIES OF MANUALS. 12mos. of from 300-540 
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STURGES (OCTAVTUS). AN INTRODUCTION TO THE STUDY 
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TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL 
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28 Lea Brothers & Co., Philadelphia and New York:. 

TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- 
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TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 

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To the student, as to the physician, I be found to be thorough, authorita- 

we would say, get Taylor first, and tive and modern. — Albany Law 

then add as "means and inclination Journal. 

enable you.— American Practitioner Probably the best work on the 



and News. 



subject written in the English Ian- 



It is the authority accepted as guage. The work has been thor- 
final by the courts of all English- oughly revised and is up to date.— 
speaking countries. The work will Pacific Medical Journal. 

ON POISONS IN RELATION TO MEDICINE AND MEDI- 
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Cloth, $5.50 ; leather, $6.50. 

TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- 
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By long odds the best work on j It is a veritable storehouse of our 
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The clearest, most unbiased and practical, full exposition of the 
ably presented treatise as yet pub- greatest value.— Chicago Clinical 
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Medical News. 

TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
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13 colored plates. Cloth, $3.00, net. Just ready. 



The author has presented to the 



followed, will be of unlimited value 



profession the ablest and most scien- to both physician and patient. — 
tific work as yet published on sexual Medical Newt. 
disorders, and one which, if carefully I 

A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 

Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 

Sages of text. Complete work now ready. Price per part, sewed in 
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TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
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802 pages. Cloth, $3.75. 



Lea Brothers & Co., Philadelphia and New York. £9 



THOMAS (T. GADLIjARD) AND MUNDE (PAUIj P.). A PRAC- 
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The best practical treatise on the 
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It will be of especial value to the 
general practitioner as well as to the 
specialist. The illustrations are very 
satisfactory. Many of them are new 
and are particularly clear and attrac- 
tive. — Boston Med . and Sur. Jour. 



This work, which has already gone 
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man, Spanish and Italian, is the 
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the most complete treatise upon the 
subject. — The Archives of Gynecol- 
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THOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS- 
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— THE PATHOLOGY AND TREATMENT OF STRICTURE 

OF THE URETHRA AND URINARY FISTULA. From the 
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THOMSON (JOHN). DISEASES OF CHILDREN. In one crown 

octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. 
In this admirable work the sub- , encroach upon any existing work, 
ject is approached from a purely j It contains many things not to be 
clinical stand-point. It differs from j found in the text-books, and is prac- 
anything that has yet appeared upon tical in the extreme. — Archives of 
diseases of children, and does not ' Pediatrics. 

TIRARD (NESTOR). MEDICAL TREATMENT OF DISEASES 
AND SYMPTOMS. Handsome octavo volume of 627 pages. Just 
ready. Cloth, $4.00, net. 



this is a work destined to become 
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This work will rapidly come into 
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ers. It deals comprehensively with 
therapeutical medications and pre- 
sents a great niimber of well-selected 
formulas of every day use. Certainly 

TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 
8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Complete work, cloth, $16.00. 



30 Lea Brothers & Co., Philadelphia and New York. 

TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In 

one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See 
Student's Series of Manuals, page 27. 

TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES 

OF CHILDREN. In one handsome 12mo. volume of 374 pages, 

with 5 plates. Just ready. Cloth, $1.50, net; flexible red leather, 

$2.00, net. Lea's Series of Pocket Text-books, edited by Bern B. 

Gallaudet, M. D. See p. 17. 

It is a good work — the author hav- 1 of infancy and childhood into short 

ing condensed most of the leading and readable chapters. — Virginia 

points in connection with diseases ' Medical Semi-Monthly. 

VAUGHAN (VICTOR C.) AND NOW (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 
or the Chemical Factors in the Causation of Disease. Third edition. 
In one 12mo. volume of 603 pages. 

The work has been brought down The present edition has been not 
to date, and will be found entirely only thoroughly revised throughout 
satisfactory. — Journal of the Ameri- j but also greatly enlarged, ample 
can Medical Association. consideration being given to the new 

The most exhaustive and most re- J subjects of toxins and antitoxins. — 
cent presentation of the subject. — Tri-State Medical Journal. 
American Jour, of the Med. Sciences. ' 

VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1900. 
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With thumb-letter index for quick use, 25 cents extra. Special rates 
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American Journal of the Medical Sciences, or both. See p. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions bv H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
ING. New (4th) edition. In one 12mo. volume of 594 pages, with 
502 engravings, many of which are photographic. $3.00, net. 

Well written, conveniently ar" 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 
work of ready reference for sur- 
geons. — North Amer. Practitioner, 



The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder, 



Lea Bbothebs & Co., Philadelphia and New York. 31 

WHITLA (WILLIAM). DICTION AEY OF TREATMENT, OR 
THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 

WHITMAN'S (ROYAL). ORTHOPEDIC SURGERY. One octavo 
volume of about 650 pages, with about 400 illustrations. Preparing. 

WILLIAMS (DAWSON). THE MEDICAL DISEASES OF CHIL- 
DREN. New (2d) edition. Specially revised for America by F. S. 
Churchill, A.M., M.D. In one octavo volume of 538 pages, with 
52 illustrations, and 2 plates. Cloth, $3.50, net. Just ready. 

diagnoses, prognosis, complications, 



The descriptions of symptoms are 
full, and the treatment recommended 
will meet general approval. Under 
each disease are given the symjatoms, 



and treatment. The work is up to 
date in every sense. — The Charlotte 
Medical Journal. 



WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 
A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; 
leather, $5. 

WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
by the Author. In one octavo volume of 484 pages. Cloth, $4. 

WIPPERN (A. G.) AND BALLENGER (W. L.). A POCKET 
TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE AND 
THROAT. In one handsome 12mo. volume of 525 pages, with 14S 
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limp leather, $2.50, net. Lea's Series of Pocket Text-books, edited by 
Bern B. Gallatjdet, M. D. See p. 17. 

WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated 
from the eighth German edition, by Ira Remsen, M. D. In one 
12mo. volume of 550 pages. Cloth, $3. 

YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New 
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Cloth, $2.50. See Series of Clinical Manuals, page 26. 

work of Dr. Yeo's. The value of 
the work is not to be overestimated. 
— New York Medical Journal. 



We doubt whether any book on 
dietetics has been of greater or more 
widespread usefulness than has this 
much-quoted and much-consulted 



YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 



In studying the different chapters, 
one is impressed with the thorough- 
ness of the work.. The illustrations 
are numerous — the book thoroughly 
practical — Medical News. 

It is a thorough, a very compre- 
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surgical specialty and every page 
abounds with evidences of prac- 
ticality. It is the clearest and most 
modern work upon this growing de- 
partment of surgery.— The Chicago 
Clinical Review. 



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PROGRESSIVE MEDICINE. 

■ *u A Q r Ui }!' te !' 1 } r Digest of New Methods, Discoveries, and Improvements 
in the Medical and Surgical Sciences bv Eminent Authorities. Edited bv 
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